Handbook of Human Immunology, Second Edition

Handbook of HUM AN IMMUNOLOGY Second CRC_1984_FM.indd i Edition 1/16/2008 6:21:32 PM CRC_1984_FM.indd ii 1/16/20...

Author: Maurice R.G. O'Gorman | Albert D. Donnenberg

118 downloads 1175 Views 18MB Size Report

This content was uploaded by our users and we assume good faith they have the permission to share this book. If you own the copyright to this book and it is wrongfully on our website, we offer a simple DMCA procedure to remove your content from our site. Start by pressing the button below!
Report copyright / DMCA form

DOWNLOAD PDF

Handbook of

HUM AN IMMUNOLOGY Second

CRC_1984_FM.indd i

Edition

1/16/2008 6:21:32 PM

CRC_1984_FM.indd ii

1/16/2008 6:21:32 PM

Handbook of

HUM AN IMMUNOLOGY Second

Edition

Edited by

Maurice R. G. O’Gorman, Ph.D. The Children's Memorial Hospital Chicago, Illinois

Albert D. Donnenberg, Ph.D. Hillman Cancer Center Pittsburgh, Pennsylvania

Boca Raton London New York

CRC Press is an imprint of the Taylor & Francis Group, an informa business

CRC_1984_FM.indd iii

1/16/2008 6:21:33 PM

Cover art by Yoju from the original artwork “Ao ni Aru Saibo”-525A. Copyright Yoju’s Studio. Used with permission. CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2008 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed in the United States of America on acid-free paper 10 9 8 7 6 5 4 3 2 1 International Standard Book Number-13: 978-0-8493-1984-6 (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequences of their use. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www. copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Handbook of human immunology / editors, Maurice R. G. O’Gorman and Albert D. Donnenberg -- 2nd ed. p. ; cm. “A CRC title.” Includes bibliographical references and index. ISBN 978-0-8493-1984-6 (alk. paper) 1. Immune system. 2. Immunology. I. O’Gorman, Maurice R. G. II. Donnenberg, Albert David. III. Title. [DNLM: 1. Immunity. 2. Immune System Diseases. 3. Immunologic Techniques. 4. Immunologic Tests. QW 540 H236 2008] QR181.H27 2008 616.07’9--dc22

2007035313

Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com

CRC_1984_FM.indd iv

1/16/2008 6:21:33 PM

Contents Preface ......................................................................................................................ix Editors .......................................................................................................................xi Contributors ........................................................................................................... xiii Chapter 1

Overview of Immunity .........................................................................1 James D. Folds

Chapter 2

Statistics of Immunological Testing ................................................... 29 Albert D. Donnenberg

Chapter 3

Human Immunoglobulins .................................................................. 63 Robert G. Hamilton

Chapter 4

The Complement System ................................................................. 107 Patricia C. Giclas

Chapter 5

Cellular Immunology: Monitoring of Immune Therapies ............... 137 Theresa L. Whiteside

Chapter 6

Understanding Clinical Flow Cytometry ......................................... 181 Albert D. Donnenberg and Vera S. Donnenberg

Chapter 7

Leukemia and Lymphoma Immunophenotyping and Cytogenetics .............................................................................. 221 Maria A. Proytcheva

Chapter 8

Guidelines for the Use of Flow Cytometry in the Management of Patients Infected with the Human Immunodeficiency Virus Type-1 and the Acquired Immunodeficiency Syndrome .......................................................... 257 Maurice R.G. O’Gorman

v

CRC_1984_FM.indd v

1/16/2008 6:21:33 PM

vi

Chapter 9

Contents

Role of Flow Cytometry in the Diagnosis and Monitoring of Primary Immunodeficiency Disease............................................ 267 Maurice R.G. O’Gorman

Chapter 10 Detection and Characterization of the T-Cell Receptor Repertoire ......................................................................... 313 Gulbu Uzel Chapter 11 Human Leukocyte Differentiation Antigens, Cluster of Differentiation: Past, Present, and Future .................................... 319 Maurice R.G. O’Gorman Chapter 12 Immunologic Diagnosis of Autoimmunity ...................................... 369 Noel R. Rose Chapter 13 Autoimmune and Immune-Mediated Diseases of the Gastrointestinal Tract ............................................................. 383 Stefano Guandalini, Mala Setty, and Bana Jabri Chapter 14 Serologic Testing for Infectious Diseases ........................................ 421 John L. Schmitz Chapter 15 Molecular Techniques Applied to Infectious Diseases .................... 441 Jennifer S. Goodrich and Melissa B. Miller Chapter 16 Cytokines: Regulators of Immune Responses and Key Therapeutic Targets .......................................................................... 495 Barbara Detrick, Chandrasekharam N. Nagineni, and John J. Hooks Chapter 17 Measuring Human Cytokines .......................................................... 517 Holden T. Maecker Chapter 18 The Human Major Histocompatibility Complex and DNA-Based Typing of Human Leukocyte Antigens for Transplantation ........................................................................... 541 Susana G. Marino, Andrés Jaramillo, and Marcelo A. Fernández-Viña

CRC_1984_FM.indd vi

1/16/2008 6:21:33 PM

Contents

vii

Chapter 19 Relevance of Antibody Screening and Crossmatching in Solid Organ, Hematopoietic Stem Cell Transplantation, and Blood Transfusion ..................................................................... 565 Chee L. Saw, Denise L. Heaney, Howard M. Gebel, and Robert A. Bray Chapter 20 Functional Assessment of Immunosuppression: Monitoring Posttransplant Alloreactivity with Flow Cytometric Mixed Lymphocyte Cocultures ................................................................... 589 Chethan Ashok Kumar, Ali Abdullah, Alison Logar, Patrick Wilson, Anjan Talukdar, Nydia Chien, Mandal Singh, and Rakesh Sindhi Index .....................................................................................................................599

CRC_1984_FM.indd vii

1/16/2008 6:21:33 PM

CRC_1984_FM.indd viii

1/16/2008 6:21:33 PM

Preface Since the publication of the first edition of the Handbook of Human Immunology in 1997, major scientific achievements have contributed directly to an increased understanding of the complexities of the human immune system in health and disease. Whether directly as a result of the sequencing of the entire human genome or as a result of the technological advancements in the completion of the latter, several new components of the immune system have been revealed, and new technologies for their measurement and evaluation have been developed. In the past decade, the number of recognized clusters of differentiation (CD) on the surface of leukocytes and associated cells has more than doubled; an entire new chemokine and chemokine receptor nomenclature system has been established; the number of “lymphokines” (now greater than 30) and humanized monoclonal antibody therapy have become a staple of our pharmacologic armamentarium (to mention only a few of the significant immunological developments of the past decade). The discovery of all of these immune system components has been accompanied by the development of new and improved methods for their detection as well as the recognition of the roles that these components play in health and disease. These major breakthroughs are reflected in the present edition of the Handbook of Human Immunology. There are six new chapters for a total of 20 (compared to 14 in the previous edition) written by 12 new authors covering all the major components of the innate and adaptive human immune system, descriptions of the specific human conditions characterized by their assessment, the specific technologies and methods currently used for their measurement, and finally the relevance and potential pitfalls involved in the interpretation of their specific measurements. As in the past, the book is introduced with an overview of the immune system, which is immediately followed by a new, practical, and fun-to-read chapter on “Statistics of Immunological Testing” that is invaluable both in interpreting test results and also in the validation of new tests and the development of reference ranges. Throughout this edition, readers will find “normal ranges” including serum immunoglobulins, complement components, cytokines, and new to this edition—age-associated normal ranges for lymphocyte subsets. The first edition’s chapter on flow cytometry has been expanded into six completely revised chapters including a thorough treatise on general flow cytometry principles and practice, quality control and theory, leukemia and lymphoma immunophenotyping analyses along with cytogenetic abnormalities, an update on CD4 measurement guidelines in HIV-infected persons and two new chapters covering (1) the flow cytometry–based diagnosis of primary immunodeficiency disease and (2) a history of the human leukocyte differentiation antigen workshops (now renamed the human cell differentiation antigen workshops) along with two comprehensive and very informative tables on CD. The chapters on clinical laboratory disease monitoring include laboratory methods for monitoring new biological therapies in the context of clinical trials and routine practice, an entire chapter devoted specifically to the immunological assessment of ix

CRC_1984_FM.indd ix

1/16/2008 6:21:33 PM

x

Preface

gastrointestinal diseases, and a global review of the laboratory assessment of autoimmune disease. Infectious disease monitoring is discussed from the serological perspective, as well as the timely review of the technology and applications of new and now well-established molecular techniques. Finally, the laboratory’s role in bone marrow and solid organ transplant is presented from the perspectives of antibody screening and crossmatching as well as molecular-based human leukocyte antigen (HLA) typing, followed by Chapter 20, which presents novel methods for monitoring functional immunosuppression of alloreactivity in patients posttransplant. This edition of the handbook provides a practical reference of the important immunological parameters along with up-to-date descriptions of the methods used for their assessment and applications in health and disease. The text is particularly relevant to practicing clinicians, clinical laboratory professionals, and students interested in human immunology both from laboratory and applied clinical perspectives.

CRC_1984_FM.indd x

1/16/2008 6:21:33 PM

Editors Maurice R.G. O’Gorman, PhD, is a professor of pediatrics and pathology at the Feinberg School of Medicine of Northwestern University, Chicago, Illinois. He is also the vice chair of the department of pathology and laboratory medicine and the director of the diagnostic immunology and flow cytometry laboratories at Children’s Memorial Hospital. Dr. O’Gorman was born in Windsor, Ontario, Canada and graduated in 1981 from the University of Western Ontario, London, Ontario, with a BSc with honors in microbiology and immunology. He then attended the University of British Columbia and earned an MSc in pathology in 1985 and 3 years later, a PhD in academic pathology from the same university. Following his doctorate, Dr. O’Gorman was awarded a 1-year fellowship in the division of neurology at UBC to develop and implement functional immune monitoring assays for clinical trials of new biological treatments for multiple sclerosis (MS). The following year Dr. O’Gorman was awarded a 2-year fellowship in clinical and diagnostic laboratory immunology in the department of pathology at the University of North Carolina in Chapel Hill. His research as a postdoctoral fellow evolved around the development, validation, and standardization of new clinical assays, many of which were flow cytometry based. In his present position at the Children’s Memorial Hospital in Chicago, Illinois, Dr. O’Gorman has established the Diagnostic Immunology and Flow Cytometry Laboratory at the Children’s Memorial Hospital as an internationally recognized laboratory for the evaluation of primary immune deficiency disorders, leukemia and lymphoma immunophenotyping, and autoimmune disease. His clinical and developmental research program encompasses broad areas in immunology, including the establishment of normal reference ranges for the pediatric population, development of surrogate markers for monitoring disease activity and response to therapy, and the development of new diagnostic tests. He is also the codirector of the CPEP accredited postdoctoral program in clinical and diagnostic laboratory immunology. His main research interests are the investigation of immunopathogenetic mechanisms and immune regulation in autoimmunity and primary immunodeficiency diseases. Dr. O’Gorman has over 100 scholarly publications, has been an invited lecturer at numerous national and international venues, and has organized and chaired several national and international conferences and training programs in immunology and flow cytometry. Dr. O’Gorman’s leadership positions have included among others, president of the Association of Medical Laboratory Immunologists (AMLI, 2001–2003); president of the Great Lakes International Image Analysis and Flow Cytometry Association (2004); editor-in-chief of Clinical Immunology Newsletter (1994–2000); editor-in-chief of Clinical and Applied Immunology Reviews (2000–2006); and reviews editor for the Journal of Immunological Methods (2007). In 2005, Dr. O’Gorman earned an MBA from the executive MBA program at the Kellogg School of Management. He is married and has two sons, and enjoys a broad variety of sports and recreational activities. xi

CRC_1984_FM.indd xi

1/16/2008 6:21:33 PM

xii

Editors

Albert D. Donnenberg was born in New York, in 1951. As an undergraduate student, he studied philosophy at the University of Colorado, Boulder. He received his PhD in infectious disease epidemiology at the Johns Hopkins University in 1980, studying cellular immunity to herpes simplex virus. On graduation, he was elected to Delta Omega, the honorary Public Health Society. After a postdoctoral fellowship under the direction of bone marrow transplant pioneer Dr. George Santos at the Johns Hopkins Oncology Center, Dr. Donnenberg was appointed instructor of oncology in 1982, assistant professor in 1983, and associate professor in 1989. He worked on adoptive transfer of donor immunity during allogeneic bone marrow transplantation, and the development and clinical use of T-cell depletion of bone marrow to prevent graft-versus-host disease, an early implementation of engineered cellular therapy. He also performed early studies on cellular immunity in human immunodeficiency virus (HIV) infection, and codeveloped the concept of T-cell homeostasis. In 1991, Dr. Donnenberg was recruited to the University of Pittsburgh to serve as the director of laboratory research for the Bone Marrow Transplant Program. He has also served as program codirector, and as interim director. He has directed the UPMC Hematopoietic Stem Cell Laboratory and the University of Pittsburgh Cancer Institute’s Flow Cytometry Facility since 1998. He was promoted to professor of medicine in 2001. His current research interests are in stem cell therapy and graft engineering, immunity after hematopoietic stem cell transplantation, and the role of stem cells in neoplasia—a project he pursues with his wife Dr. Vera Donnenberg. He is internationally recognized for his work in somatic cell therapy and flow cytometry. Dr. Donnenberg has authored more than 130 scholarly publications. He is the proud father of four daughters and one son, and lives on Pittsburgh’s Southside with hobbies such as winemaking and art collecting.

CRC_1984_FM.indd xii

1/16/2008 6:21:34 PM

Contributors Ali Abdullah Department of Pathology University of Pittsburgh Pittsburgh, Pennsylvania Robert A. Bray Department of Pathology and Laboratory Medicine Emory University School of Medicine Atlanta, Georgia Nydia Chien Department of Pathology University of Pittsburgh Pittsburgh, Pennsylvania Barbara Detrick Department of Pathology Johns Hopkins School of Medicine Baltimore, Maryland

James D. Folds Department of Pathology and Laboratory Medicine University of North Carolina at Chapel Hill Chapel Hill, North Carolina Howard M. Gebel Department of Pathology and Laboratory Medicine Emory University School of Medicine Atlanta, Georgia Patricia C. Giclas Department of Pediatric Allergy and Immunology National Jewish Medical and Research Center Denver, Colorado

Albert D. Donnenberg Department of Medicine Division of Hematology and Oncology University of Pittsburgh Pittsburgh, Pennsylvania

Jennifer S. Goodrich University of North Carolina Hospitals Chapel Hill, North Carolina

Vera S. Donnenberg University of Pittsburgh Schools of Medicine and Pharmacy UPMC Heart Lung and Esophageal Surgery Institute Pittsburgh, Pennsylvania

Stefano Guandalini Department of Pediatrics Comer Children’s Hospital University of Chicago Chicago, Illinois

Marcelo A. Fernández-Viña Department of Pathology and Laboratory Medicine MD Anderson Cancer Center University of Texas Houston, Texas

Robert G. Hamilton Department of Medicine Division of Allergy and Clinical Immunology Johns Hopkins School of Medicine Baltimore, Maryland xiii

CRC_1984_FM.indd xiii

1/16/2008 6:21:34 PM

xiv

Contributors

Denise L. Heaney Department of Pathology and Laboratory Medicine Emory University School of Medicine Atlanta, Georgia

Melissa B. Miller Department of Pathology and Laboratory Medicine University of North Carolina at Chapel Hill Chapel Hill, North Carolina

John J. Hooks Laboratory of Immunology National Eye Institute National Institutes of Health Bethesda, Maryland

Chandrasekharam N. Nagineni Laboratory of Immunology National Eye Institute National Institutes of Health Bethesda, Maryland

Bana Jabri Department of Pathology Comer Children’s Hospital University of Chicago Chicago, Illinois

Maurice R.G. O’Gorman Department of Pathology and Pediatrics Feinberg School of Medicine Northwestern University Chicago, Illinois

Andrés Jaramillo Department of Pathology Rush University Medical Center Chicago, Illinois Chethan Ashok Kumar Department of Pathology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Alison Logar Department of Pathology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Holden T. Maecker BD Biosciences Becton, Dickinson and Company San Jose, California Susana G. Marino Department of Pathology University of Chicago Chicago, Illinois

CRC_1984_FM.indd xiv

Maria A. Proytcheva Department of Pathology Feinberg School of Medicine Northwestern University Chicago, Illinois Noel R. Rose Departments of Pathology and Molecular Microbiology and Immunology Johns Hopkins University Baltimore, Maryland Chee L. Saw Department of Pathology and Laboratory Medicine Emory University School of Medicine Atlanta, Georgia John L. Schmitz Department of Pathology and Laboratory Medicine University of North Carolina at Chapel Hill Chapel Hill, North Carolina

1/16/2008 6:21:34 PM

Contributors

xv

Mala Setty Department of Pediatrics Comer Children’s Hospital University of Chicago Chicago, Illinois

Gulbu Uzel National Institute of Allergy and Infectious Diseases National Institutes of Health Bethesda, Maryland

Rakesh Sindhi Department of Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Theresa L. Whiteside Department of Pathology University of Pittsburg School of Medicine Pittsburgh, Pennsylvania

Mandal Singh Department of Pathology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Patrick Wilson Children’s Hospital of Pittsburg of UPMC Pittsburgh, Pennsylvania

Anjan Talukdar Department of Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

CRC_1984_FM.indd xv

1/16/2008 6:21:34 PM

CRC_1984_FM.indd xvi

1/16/2008 6:21:34 PM

1 Overview of Immunity James D. Folds CONTENTS 1.1 Introduction .......................................................................................................1 1.2 Overview of Innate Immunity ..........................................................................2 1.2.1 Antimicrobial Peptides ..........................................................................2 1.2.2 The Complement System .......................................................................4 1.2.3 Natural Antibodies (or Immunoglobulins) ............................................6 1.2.4 Toll-Like Receptors ...............................................................................6 1.2.5 Phagocytosis ..........................................................................................8 1.2.6 Cytokines and Chemokines................................................................. 10 1.2.7 Natural Killer Cells ............................................................................. 11 1.2.7.1 Natural Killer T Cells ............................................................ 13 1.2.8 Gamma/Delta T Lymphocytes ............................................................ 14 1.2.9 Dendritic Cells..................................................................................... 14 1.2.9.1 Immature Dendritic Cells ...................................................... 15 1.2.9.2 Mature Dendritic Cells .......................................................... 15 1.2.10 Overview of Adaptive Immunity......................................................... 18 1.2.11 B Lymphocytes .................................................................................... 18 1.2.12 T Lymphocytes ....................................................................................20 1.2.13 Comments ............................................................................................ 23 References ................................................................................................................ 23

1.1

INTRODUCTION

The events leading to the development of immunity directed against pathogens are exceedingly complex. There are two distinct systems—innate and adaptive—that act in concert as well as separately in the development of immunity. The innate system provides a first line of defense against a foreign substance. It is nonspecific, rapid, lacks immunologic memory, and is usually of short duration. The adaptive system has exquisite specificity, is slower in development, exhibits immunological memory, and is long lasting. Innate and adaptive immune systems are distinct systems but interact at several levels to develop a complete defense against invading pathogens. Both systems have mechanisms for distinguishing self from nonself, therefore, under normal situations they are not directed against the host’s tissues and cells. 1

CRC_1984_CH001.indd 1

1/5/2008 11:47:22 AM

2

Handbook of Human Immunology, Second Edition

This chapter is intended to provide an introduction to the development of immunity. The purpose is to provide an overview of the different cells involved in both systems and the interactions occurring between the cells. The vigorous signaling mechanisms and the regulatory cells and enhancer and suppressor substances will be discussed in the context of developing immunity. This chapter serves as a broad overview.

1.2 OVERVIEW OF INNATE IMMUNITY Elements of the innate immune system have been known for many years. However, in the past few years there has been a greater focus on innate immunity and its role in protection against infection and tissue injury [1] and its role in tolerance to selfantigens. Innate immunity defines a collection of protective mechanisms the host uses to prevent or minimize infection. The innate immune system operates in the absence of the specific adaptive immune system but is tied to adaptive immunity in many ways. The innate immune system is characterized by a rapid response to an invading pathogen or foreign or effete cells. In addition to the rapid response, it is also nonspecific and usually of a short duration. Innate immunity lacks immunological memory and there is no clonal expansion of lymphocytes as seen in the adaptive immune response. The innate immune response is also important in directing the specific, long-lived adaptive immune response. The host defense mechanisms associated with innate immunity consist of a number of physical barriers (intact skin) and secretions accompanied by a number of serum factors such as complement, certain cytokines, and natural immunoglobulins [2]. The cellular components of innate immunity include a number of cell types, many of which are found at potential points of entry of pathogens [3]. Examples of these cells include natural killer (NK) cells, polymorphonuclear neutrophils (PMNs), macrophages, and dendritic cells (DCs). The intact skin and mucosal tissues provide considerable protection against invading infectious agents. However, once the agents pass through the skin a number of important events take place. This includes activation of the complement cascade that triggers the development of a number of substances to attract phagocytes to the area. A number of antimicrobial peptides are produced at epithelial cell surfaces. These antimicrobial peptides play an important role in local defense mechanisms, disrupt bacterial cell membranes, and probably play a role in preventing skin infections.

1.2.1

ANTIMICROBIAL PEPTIDES

Human β-defensins are produced by epithelial cells in the mucous membranes of the airways and intestinal tract [4]. Defensins are small cationic peptides that have broad antimicrobial activities against a number of microbial agents [4] including Gram-positive and Gram-negative bacteria, fungi, and enveloped viruses. Defensins are nonglycosylated peptides containing approximately 35 amino acid residues, and β-defensins have six cysteine residues that provide a distinct structure. Stimulation of the epithelium by certain cytokines can induce defensin production. The exact mode of action of defensins’ antimicrobial activity is unknown. It is likely that defensins cause membrane disruption resulting from electrostatic interaction with the polar head groups of membrane lipids [5].


1/5/2008 11:47:22 AM

Overview of Immunity

3

There are three defensin subfamilies: α-defensins, β-defensins, and θ-defensins [5]. The α- and β-defensins are products of distinct gene families and are structurally different from the θ-defensins. The θ-defensins are not seen in humans and probably represent a mutated form of the α-defensins. The α-defensins were first purified from azurophilic granules of PMNs [6]. Several species, including rabbits, humans, and some rodents have α-defensins in their PMNs. Human monocytes and NK cells produce α-defensins that are similar to the α-defensins of PMNs [6]. The α-defensins play a role in the oxygen-independent killing of microorganisms after phagocytosis by PMNs [5]. The β-defensins are expressed in epithelial cells and leukocytes throughout the body. The β-defensins work in concert with a number of other components of the innate system to provide an important defense against microorganisms. There are at least four human β-defensins (HBD-1–HBD-4) [7]. Production of β-defensins may be constitutive or inducible. HBD-2, -3, and -4 are inducible. There is evidence that certain epithelial cells can be stimulated to produce HBD-2 in response to activation by bacterial products and toll-like receptors (TLRs) found on the epithelial cells [7]. Defensins also appear to have immunoregulatory properties in addition to their antimicrobial properties [8]. Immunoregulatory properties include chemoattractants for PMNs, immature DCs (iDCs), mast cells, and some memory T cells. Defensins may also stimulate iDCs to undergo maturation [8]. Several other antimicrobial peptides have been described in epithelial cells and PMNs. Lysozyme was described as an antimicrobial peptide found in human neutrophils and is known to attack the peptidoglycan cell walls of bacteria. Cathelicidin is expressed in human cells such as epithelial cells, PMNs, monocytes, and T, B, and NK cells [9]. It is usually expressed by cells lining the respiratory and gastrointestinal tracts. Cathelicidin is a well-known chemoattractant for various cells including PMNs, mast cells, monocytes, and thymus-derived lymphocytes (T lymphocytes). Cathelicidin has antimicrobial activity against most Gram-positive and Gram-negative bacteria. Histatins are a family of cationic peptides (MW = 3–4 kDa) that are present in human saliva [6]. Histatins probably play an important role in oral health by providing potent antibacterial and antifungal actions. Of the several known histatins, histatin 5 is the most potent antifungal agent and is secreted by human parotid and submandibular glands [10]. The human skin, when intact, is refractory to most pathogens. This natural resistance is reportedly due to the presence of constitutively produced and inducible antimicrobial peptides. These peptides are cathelicidins, defensins, and dermicidins [9,7,11]. These antimicrobial peptides appear to act by directly inhibiting pathogen growth and enhancing other components of the immune responses. Psoriasin is another antimicrobial peptide found in the skin, especially in areas where bacterial invasion is likely to occur [12]. Psoriasin shows bactericidal activity preferentially against Escherichia coli, and also shows activity against other organisms that may colonize the skin. Together, these antimicrobial peptides and proteins contribute significantly by providing a “chemical barrier” to reenforce the physical barriers of the intact skin and mucous membranes.


1/5/2008 11:47:23 AM

4

1.2.2


THE COMPLEMENT SYSTEM

The complement system is another important component of innate immunity. The system consists of 30 proteins found in serum or on the surface of certain cells [13]. Activation of the complement system results in a cascade of biochemical reactions that ultimately ends in lysis and disruption of foreign or effete cells. Without activation, the components of the complement system exist as proenzymes in body fluids. As a by-product of the activation of the cascade, a number of biologically reactive complement fragments are generated. The complement fragments can modulate other parts of the immune system by binding directly to T lymphocytes and bone marrow–derived lymphocytes (B lymphocytes) of the adaptive immune system and also stimulate the synthesis and release of cytokines. As shown in Figure 1.1, there are three activation pathways for the complement system. Although the activation pathways are different, they all act at the microbial surface to assemble an enzyme convertase that cleaves C3 to form C3b that binds to a microbial surface where it activates C5 and the other components of the cascade. The three pathways are the classical, mannan-binding lectin (MBL), and the alternative. Each of the pathways has its own recognition mechanism and is activated through different mechanisms, but all result in the formation of a membrane attack complex (MAC) and lysis of a target cell. The classical pathway is activated by either IgM or IgG attached to a microbial surface antigen. The recognition molecule for the classical pathway is complement component C1q. A conformational change occurs in C1q, which results in activation of C1r and C1s, which, in turn, activates C4 and C2, which leads to the formation of the C4b2a complex (C3 convertase). The C3 covertase acts on C3, which ultimately leads to the formation of the MAC. Activation of the MBL pathway begins after the recognition of mannose-binding lectin on various carbohydrate ligands [14]. MBLs and ficolins are found in serum and are structurally similar to C1q. MBLs and ficolins bind to mannose-containing carbohydrates on the surface of microbes. The MBLs and ficolins are considered to be typical pattern recognition molecules and as such attach to the MBL-associated serine proteases. On activation, the MBL-associated serine proteases cleave C4 and C2 to generate the C3 convertase C4bC2a and activate the remainder of the cascade [15]. The alternative pathway is important in innate immunity because it does not require specific antibodies for activation of C3. There are low levels of C3 present in body fluids at all times. C3 undergoes hydrolysis to produce C3(H2O), which is an activated form. C3(H2O) can bind to factor B that is then cleaved by the factor D to form the fluid-phase C3 convertase C3(H2O)Bb. Small amounts of C3b are needed to activate the alternative pathway at microbial surfaces [16]. C3b on the microbial surface binds to factor B, which is cleaved by factor D to form C3bBb, the C3 convertase. Properdin serves to stabilize the convertase whose role is to cleave C5, which activates the remainder of the cascade. There are several agents that can activate the alternative pathway: bacterial cells, tumor cells, enveloped viruses, and damaged mast cells. The complement system and its by-products serve to facilitate opsonization and may ultimately remove or destroy invading microorganisms. Tissue and circulating PMNs and macrophages are the cells that are most often involved in the ingestion


1/5/2008 11:47:23 AM


5

Classical

Mannan-binding lectin

Alternative

Activated by IgM, IgG bound to microbial surface antigens

Activated by recognizing MBL and ficolin of carbohydrate ligands

Activating surfaces (bacterial), LPS IgA

MBL Ficolins

C1q

C3H2O (hydrolyzed C)

B

C2

D C4

C4b2a

Properdin

C3bBb

C3

C3b C5 C6 C7 C8 C9

Membrane attack complex

FIGURE 1.1 The three pathways of complement activation. (Modified from Seeleen, M., Roos, A., Daha, M.R., J. Nephrol., 18, 642–653.)

of intracellular pathogens and killing of the invading microbes. Surface-bound C3b and iC3b (on the microbes) facilitate the attachment of the microbes to phagocyte complement receptors, which activates the ingestion and intracellular killing by the phagocytes [17]. In addition to enhancing opsonization in the presence or absence of antibodies, complement components have other important biological functions [17]. For example, free cleavage fragments of C3 and C5 are known to promote host inflammatory responses. C3a and C5a stimulate the bone marrow to release additional PMNs (C3b) and to serve as strong chemoattractants (C3a) for PMNs, monocytes, and eosinophils. Complement components C4a and C5a behave as anaphylotoxins


1/5/2008 11:47:23 AM

6


to induce histamine release, which, in turn, causes increased vascular dilatation and permeability. As mentioned earlier, the complement system helps modulate the adaptive immune response by enhancing antigen recognition and by stimulating the synthesis and release of cytokines. Together, the complement system is another important factor in defense against invading microbes and it functions to provide a rapid response.

1.2.3

NATURAL ANTIBODIES (OR IMMUNOGLOBULINS)

Natural antibodies have been recognized for some time but recently they were described as a component of the innate immune system [18]. Natural antibody is defined as an antibody that is found in normal, healthy individuals who have no evidence of exogenous antigenic stimulation. Natural antibodies are believed to develop in a highly regulated manner; they are usually found in low titer in serum and are low-affinity antibodies [17]. A high percentage of the natural antibodies found in serum are of the IgM class. These antibodies are produced by a primitive B lymphocyte, called the B-1 lymphocytes [18]. B-1 cells are usually CD5+ and considered to be long-lived and self-replicating. Natural antibodies play an important role as a first line of defense against pathogens and other types of cells, including precancerous, cancerous, cell debris, and some self-antigens [19]. The cells of innate immunity apparently rely on an array of nonclonally expressed “pattern-recognition receptors (PRRs)” found in the target cells [20]. This response does not recognize specific single antigenic structures or epitopes, as in adaptive immunity, but respond to specific patterns, which are expressed independent of mutational events. This recognition system allows the innate immune mechanism to respond rapidly by focusing on structures most likely found in pathogens or effete cells. The B-1 cells are positioned at possible sites of entry of pathogens, along with monocytes, to mediate a rapid response to pathogens. The B-1 lymphocytes differ from the usual B lymphocyte (B-2) in terms of phenotype, anatomic location, and mechanisms of activation and signaling [21]. Thus, innate immunity uses an inherited set of receptors found on NK cells, γδ T cells, and CD5+ B cells to recognize and interact with a broad spectrum of different antigens.

1.2.4

TOLL-LIKE RECEPTORS

TLRs are found on phagocytic cells, including mononuclear phagocytes, circulating monocytes, tissue macrophages, and endothelial cells, and are important components of the innate immune system [22]. TLRs make up a family of cell surface protein receptors present on several cell types that function to recognize certain conserved molecular components of microorganisms and signal that microbes have breached the body’s barrier defenses [23]. TLRs serve as first responders in a mammalian host to recognize the presence of an invading pathogen. They also generate an inflammatory response to attempt to remove the invading agent. There are at least


1/5/2008 11:47:23 AM


7

TABLE 1.1 Toll-Like Receptors in Mammals Receptors TLR-1 TLR-2 TLR-4 TLR-5 TLR-6 TLR-7 TLR-8 TLR-9 TLR-10

Functions and Ligands Triacyl lipopeptides—from Mycobacteria TLR-1 is a coreceptor with TLR-2 Peptidoglycans, lipoproteins, lipoteichoic acids, Mycobacteria, and spirochetes Lipopolysaccharide, heat shock protein Bacterial flagellin Lipoteichoic acid, zymosan diacyl lipopeptides TLR-6 is a coreceptor with TLR-2 Single-stranded RNA from viruses Single-stranded RNA from viruses Cytidine–phosphate–guanosine nucleotides (CpG)—natural or synthetic unmethylated Unknown

Source: Adapted from Sigal, L.H., J. Clin. Rheumatol., 10, 353, 2004.

10 TLRs in humans and they are capable of detecting a broad range of microbial ligands (see Table 1.1). The primary role of TLRs, as mentioned earlier, is to recognize and control bacterial infection. The mechanism of recognition is based on the receptor binding to a structurally conserved and unique pathogen-associated molecular pattern (PAMP) [24]. PAMPs are structural components of microbes that are important to them physiologically and are expressed on the pathogen but not on the host cells. TLRs consist of a family of “PRRs,” which are inherited molecules that exist as transmembrane proteins that detect the presence of pathogenic agents. The recognition mechanism between the TLRs and PAMPs provides an efficient method for self/ nonself discrimination. The interaction between the TLR and the microbial PAMPs triggers host cell activation [24]. Despite intensive investigations, the molecular details of the interaction between TLRs and pathogens is still unclear. Binding sites for the different PAMPs are known to contain different extracellular leucine-rich repeat units. However, binding and recognition of many diverse bacterial ligands is not understood. After a TLR binds to a PAMP, the TLR dimerizes either with itself or, in other cases, it binds with a different TLR to induce an intracellular conformational change, resulting in the recruitment of certain other proteins (adaptor proteins) in the cytoplasm [25]. These adaptor proteins, such as MyD88, CD14, and others, transmit the message that TLR activation has occurred and initiate an intracellular cascade resulting in induction of an inflammatory response [26]. Activation of some TLRs induces the expression of a costimulatory molecule, B7 (CD80), which is found on antigen-presenting cells (APCs) and is needed for activation of naïve T lymphocytes [27]. Table 1.1 gives a listing of the TLRs found in mammals. TLRs of humans primarily recognize microbial structures and PAMPs and go on to trigger host cell activation and inflammation. In summary, TLRs function to curb an acute infection by activation and regulation of rapid effector responses in the innate immune system. TLR activation


1/5/2008 11:47:23 AM

8


regulates a number of systems known to be important in innate immunity. These include the release of inflammatory cytokines and chemokines, the oxidative burst in phagocytic cells, as well as the activation of various cationic peptides. TLRs serve to discriminate between self and nonself through the recognition and reactivity to PAMPs that are not expressed on host cells. TLRs also impact and moderate the adaptive immune response system through the induction of costimulatory molecular and cytokines that are involved in T- and B-lymphocyte reactivity.

1.2.5

PHAGOCYTOSIS

Polymorphonuclear neutrophilic leukocytes have been well-known components of the innate immune system for many years. Detailed studies of PMN phagocytosis and intracellular killing of microorganisms have led to a better understanding of important defense mechanisms against invasion by pathogenic bacteria, fungi, and enveloped viruses. PMNs are attracted to the site of microbial invasion, recognize the microbe, become activated, kill the microorganisms, resolve the infection, undergo apoptosis, and are then ingested and removed by either macrophages or neighboring endothelial cells to resolve the inflammatory response. PMNs arise as myeloid progenitors in the bone marrow. Specific growth factors and cytokines mediate the differentiation of myeloid precursors into mature PMNs [28]. After entering the circulation, the PMNs have a half-life of about 8–12 h before undergoing a programmed cell death (apoptosis) and are reabsorbed through endothelial walls. The PMN turnover is about 1011 cells per day [29]. PMNs are actively recruited to the site of an infection by a complicated multistep process whereby they are mobilized both from the circulation and bone marrow. PMNs are constantly rolling along walls of the postcapillary venules where they readily detect the presence of a chemoattractant signal generated either by endothelial cells or the microbes themselves [30]. The chemokine, interleukin-8 (IL-8), is an important chemoattractant produced by multiple host cell types during an inflammatory event [31]. Bacteria also produce substances that are chemoattractants for PMNs. Once the PMNs reach the site, they become primed and develop enhanced functional capabilities [32]. Phagocytes are actively recruited to the site of microbial invasion as a response to a number of lectin glycoproteins called selectins [33]. Selectins are found on the surface of endothelial cells lining the blood vessels at the site of infection. P-selectin (from activated platelets) is upregulated on the surface of the endothelial cells and the selectins facilitate the “rolling and tethering” of PMNs [30]. PMNs secrete several molecules to support their migration from the circulation through the endothelium into the tissues. A number of neutrophil chemoattractants have been reported, including C5a, N-formyl bacterial oligopeptides, and leukotriene B4 [34]. As PMNs move toward the site, they become activated or primed to produce their antibacterial substances [32]. Phagocytosis is the process whereby PMNs recognize, bind, and ingest the microorganisms that stimulated the inflammatory reaction. Phagocytosis is greatly enhanced by opsonization of the bacteria. Attachment of a specific IgG or complement fragment, C3, can greatly enhance the efficiency of phagocytosis, although


1/5/2008 11:47:23 AM


9

phagocytosis can occur without opsonization [35]. Complement receptors, CR1 and CR3, are the primary receptors for opsonization by the complement. The PMNs also express receptors for IgG fragment Fc (FcγRs) facilitates phagocytosis [36]. The two most prominently expressed Fcγ receptors on circulating PMNs are known as FcγRII (CD32) and FcγIII (CD16), and binding to these receptors triggers the oxidative burst in PMNs. The binding of antibody and complement receptors at the PMNs surface activates phagocytic process. Activation of phagocytosis causes changes in the cytoskeletal contractile elements, which leads to an invagination of the cell membrane of the PMNs. This occurs at the site of the attachment of the opsonized microorganism [37]. Pseudopods extend from the PMNs and fuse around the invagination encasing the microorganism inside the phagolysosomal vacuole [37]. The PMNs have two broad types of killing mechanisms. One is oxygendependent and the other is oxygen-independent [38]. Phagocytosis of microbes stimulates the production of superoxide radicals and other reactive oxygen species. These are potent microbicidal agents and include, among others, hydrogen peroxide and chloramines. The enzyme NADPH oxidase is found in the cell membrane of the PMNs and generates the superoxide (called the respiratory burst) [38]. The superoxide is unstable and quickly dismutates to hydrogen peroxide and other substances that are microbicidal. These reactions take place inside the phagolysosome (also called phagosome). The PMNs contain two types of cytoplasmic granules, azurophilic and specific (also referred to as secondary and tertiary granules) [39]. Each type of granule houses a number of proteins and peptides with microbicidal properties. Lysozyme is found in both types of granules and cleaves peptidoglycans of bacterial cell walls to disrupt the microbes [40]. The azurophilic granules contain a number of small cationic proteins with microbicidal activity. Azurophilic granules also contain myeloperoxidase (MPO), which during PMN activation is directed to phagosomes where it catalyzes a reaction with chloride and hydrogen peroxide to form hypochlorous acid [37], which is extremely microbicidal. The beta2 integrin CD11b/CD18 is present in the plasma membrane and secondary granules of neutrophils, and functions as a major adhesion molecule. On PMN activation, there is translocation of intracellular pools of CD11b/ CD18 to the plasma membrane in concert with enhanced cellular adhesion. Although much is known about the function of CD11b/CD18, how this protein is transported within the cell is less well defined. α-Defensins are also found in azurophilic granules. These are small cationic peptides that can interact with negatively charged molecules at the pathogen surface to change the permeability of the bacterial cell membranes and cause death [41]. Lactoferrin is an iron-binding protein found in azurophilic granules and is capable of binding iron, which is needed for bacterial growth [42]. Iron is also needed by the PMN to form other antibacterial compounds. After death of the invading microorganisms, the PMNs also die through a process known as apoptosis. This process is affected by both proinflammatory host reactions and microbes and is important in the resolution of the inflammatory process. Phagocytosis is well known and extremely important to host defenses as noted by the severe infections seen in patients with phagocytic defects.


1/5/2008 11:47:24 AM

10

1.2.6


CYTOKINES AND CHEMOKINES

Cytokines and chemokines are small, secreted polypeptides that regulate essentially all functions of the immune system. Cytokines participate in determining the nature of the immune response by regulating or controlling cell growth, differentiation, activation, immune cell trafficking, and the location of immune cells within the lymphoid organs [43]. Cytokines are a group of “intercellular messengers” that contribute to inflammatory responses through activation of the host’s immune cells. Cytokines are host-derived products that enhance the recruitment of circulating leukocytes as a response to the presence of pathogens [44]. Cytokines also play important roles in leukocyte attraction by inducing the production of chemokines, which are known to be potent mediators of chemoattractant activity for inflammatory cells. Chemokines and cytokines provide a complex network of signals that can either activate or suppress inflammatory responses [44]. Cytokine secretions can alter the behavior or properties of that cell itself as well as the behavior of surrounding tissue cells. Cytokines are produced by many different cells. One cell type is capable of making many different cytokines and a particular cytokine may be secreted by multiple cell types. A particular cytokine may have many different effects on different cells depending on the environment. In some cases, the target cell itself may produce a cytokine that influences itself as well as the neighboring cells of the target cell. Some cytokines require cell-to-cell interaction to exert their effects [45]. Chemokines are another family of small structurally similar polypeptides that can regulate the trafficking of subsets of leukocytes [46]. Chemokines differ from other cytokines because all chemokines are ligands for the G-protein-coupled receptors [44]. Chemokines are potent cell activators capable of inducing migration of immune and inflammatory cells. Most cells in the immune system express receptors for at least one chemokine. Inflammatory cells may release a variety of chemokines and there is some evidence that infection with certain bacteria and viruses can stimulate the host cells to produce characteristic sets of immune cells. Cytokines have multiple, broad properties. For example, cytokines may work effectively in concert with or in competition with both immune and nonimmune cells [47]. In addition to their impact on innate immunity, cytokines support B- and T-lymphocyte maturation and proliferation, differentiation of T helper cells into Th1 and Th2 subsets, maturation and polarization of DC subtypes and memory cell development [48]. These are important facets of adaptive or acquired immunity. There have been more than 30 cytokines described [49]. Most cells of the immune system and many other host cells release cytokines. In some cases, the same cell type may respond to cytokines through specific cytokine receptors and may release and respond to the same cytokines it just produced. Two cytokines, IL-1 and tumor necrosis factor-α (TNF-α) play important roles in responses to bacterial infection [49,50]. They are both small polypeptides that exert a broad range of effects on multiple host reactions, including immunologic responses, inflammation, and hematopoiesis. Experimentally, IL-1 and TNF-α if injected into mice may produce many of the features of Gram-negative sepsis in the absence of infection with the microorganisms [49]. In endotoxic shock caused by


1/5/2008 11:47:24 AM


11

Gram-negative organism, the cytokines, IL-1 and TNF-α are secreted by mononuclear phagocytes in response to activation by TLRs by the bacterial lipopolysaccharides [49]. This reaction results in the secretion of other cytokines and chemokines, which exacerbate the reaction. Other cytokines have important roles in cell development, for example, they impact myeloid cell progenitor cell development, enhance IgG4 subclass development, regulate Th2 responses, cause mast cell proliferation in vitro, stimulate B-cell production, activate and stimulate growth of eosinophils, stimulate survival and expansion of immature precursors that are committed to T- and B-cell lineages, stimulate endothelial cells to produce adhesion molecules, enhance PMN recruitment, and many other functions. For review, see Refs. 44 and 51 and Figure 1.1.

1.2.7

NATURAL KILLER CELLS

NK cells were first reported in the 1970s. Initially, NK cells were referred to as nonspecific lymphocytes because NK cells could kill certain virally infected and malignant cells without known prior sensitization. NK cells were known to resemble large lymphocytes morphologically and were referred to as large granular lymphocytes. Approximately, 10–15% of the lymphocytes circulating in peripheral blood are NK cells. NK cells are distinct from T- and B lymphocytes because they express neither immunoglobulin receptors nor T-cell antigen receptors. There are other distinctions including phenotype and function. NK cells have receptors that recognize major histocompatibility complex (MHC) class I antigens. Because NK cells have cytotoxic properties, their function is highly regulated in their interactions in both the innate and adaptive immune systems [52,53]. NK cells develop from a common lymphoid progenitor cell in the bone marrow. The NK cells diverge from other lymphocyte lineages and acquire specific cell surface markers to guide them through their developmental stages. After developing and maturing in the bone marrow, the NK cells migrate and circulate in the peripheral blood and may be found in various organs including the lung, liver, spleen, and uterus. On antigenic stimulation, NK cells rapidly “home” to the lymph nodes and lymphatics. NK cells play important roles in innate immune responses and immune regulation. They communicate with other cells through a complex of both activation and inhibitory signals through cell surface receptors. There are many recognizable NK cell subsets [40–50] found in peripheral blood [54]. NK cells were first defined by a lack of B- and T-cell surface markers but the NK cells are now identified into subsets based on the expression of certain phenotypic surface markers. Most NK cells express a neural cell adhesion marker called CD56. Staining with a monoclonal antibody to CD56 permits division into two major subsets, CD56bright and CD56dim . CD56bright NK cells are characterized by having an expression of many CD56 surface molecules [55]. These cells have lower levels of some of the cytotoxic molecules such as perforin and express high levels of cytokines. CD56bright NK cells are thought to be important in inflammatory responses and probably play a role in immune regulation. NK cells are distinct from NKT cells that express CD3, and rearrange their germline DNA T-cell receptor (TCR) genes [55].


1/5/2008 11:47:24 AM

12


In contrast, CD56dim NK cells are the most effective killer lymphocytes. The CD56dim NK cells make up about 90–95% of NK cells in peripheral blood and they also express CD16 (Fcγ receptor) on their surface. In contrast to CD56bright NK cells, these NK cells express large amounts of perforin that mediates cytoxicity. Perforindependent cytoxicity is the major mechanism of NK cell lysis of target cells [55]. NK cells are programmed to kill target cells and they are inherently capable of killing autologous cells. They are actively inhibited from killing “self” cells by inhibitory receptors and signals. The MHC defines “self” and it has been suggested that “self-MHC” surface receptors engage the inhibitory receptors on the NK cell and prevent lysis of “self” cells [56]. Viral infection of a cell causes a change in the MHC class I expression, which in turn removes the normal inhibitory signal and NK cell activation occurs, resulting in cytotoxicity and death of the viral-infected cells. There are two families of inhibitory receptors affecting NK cells [57]. The bestdescribed inhibitory signals are those transduced by HLA-specific receptors and are members of the inhibitory killer immunoglobulin-like receptor family (KIR). There is another family of inhibitors that are lectinlike receptors identified as NKG2A/3. It is believed that the net sum of activation and inhibition signals tightly regulates the function of NK cells [55]. NK cells recognize and lyse pathogen-infected cells and malignant cells [58]. They also play an important immunoregulatory role. There are several mechanisms used by NK cells to remove cells. NK cells are effective killers by releasing large number of cytolytic granules at the site of interaction with the target. A major component of the NK cell lysosomal granules is perforin, which, as mentioned earlier, is the major cytolytic substance [58]. The cytokine and chemokine secretions of NK cells are involved in the death of target cells [52]. NK cells produce IFN-γ, TNF-α, GM-CSF, IL-5, and IL-13 among other active substances. Some antiviral activity can be attributed to cytokine production by NK cells. NK cells are known to express costimulatory molecules for T- and B-lymphocytes and activate the adaptive immune system [59]. TLRs are also expressed on NK cells and these receptors participate in the early detection of an impending infection. NK cells are activated by cytokines produced by virally infected APCs, which may result in cell lysis. At the same time, NK cells may interact with DCs to participate in generating an adaptive immune response. NK cells and DCs interact to induce DCs maturation through cytokines produced by NK cells [52]. NK cell biology is very complex and appears to be directly or indirectly involved in establishing and maintaining immunity. By expression of cell surface receptors, NK cells may go through several stages of maturation and the by-products of maturation affect most components of immunity. The balance between activation and inhibition is closely regulated in the environment where NK cells and other types of immune cells exist. Patients have been described with various NK cell abnormalities. The most prevalent observation is unusual susceptibility to certain types of viral infections primarily (herpes) [60,61]. In any case, NK cell deficiency must be rigorously documented. Most NK cell enumeration studies are performed using peripheral blood, which may not give an accurate reflection of the numbers of functional NK cells


1/5/2008 11:47:24 AM


13

available. Functional assays are difficult to perform and quantify but it is possible to determine cytolytic function and cytokine secretory properties of peripheral blood NK cells. Patients have been reported with normal numbers of peripheral blood NK cells but with a deficiency of perforin, which would impact cytoxicity. 1.2.7.1 Natural Killer T Cells Natural killer T (NKT) cells are a subset of T lymphocytes that share some properties of NK cells and conventional T cells. Classical NKT (or type 1) cells are CD1drestricted T cells that express a semi-invariant TCR Vα24-Jα18, which distinguishes them from CD1d-dependent T cells that do not express this semi-invariant TCR (type 2 NKT cells) [62]. Most NKT cells express both an invariant TCR and the NK receptor NK1.1 type 1; CD1d-restricted NKT cells are found primarily in the liver, thymus, spleen, and bone marrow [63]. Cells with type 1 TCR can be activated by a synthetic ligand α-galactosylceramide (α-GalCer) presented on CD1d [64]. Type 2 or nonclassical NKT cells fail to be activated by α-GalCer [65]. An endogenous ligand for type 1 NKT cells was identified as a lysosomal glycosphingolipid [66]. There are distinct subsets of CD1d-restricted T cells. NK cell associated markers were expressed primarily within the CD4− CD8− Vα 24 NKT subset. However, both CD4+- and CD4− CD8− Vα 24 NKT cells were capable of Th1 cytokine production. This includes IFNγ and TNF-α. The Th2 cytokines, such as IL-4 and IL-13, were secreted by the CD4+ subset [67]. Both the CD4+ and the CD4− CD8− Vα 24 NKT exist wherever other T lymphocytes are found. The fact that NKT cells recognize glycolipid antigens in association with CD1d (a nonclassical antigen-presenting molecule) sets the NKT cells apart from conventional T cells. Type 1 NKT cells recognize both foreign and self-glycolipids. Recently, it has been shown that type 1 NKT cells recognize various types of glycolipids and related compounds found in a number of parasites and bacteria but the specific ligands have not been identified. This suggests that the classical NK cells focus activity on viruses and viral infection while NKT cells, however, are primarily involved in detection of parasite and bacterial pathogens [68]. On activation, NK cells respond within a few hours with vigorous production of cytokines [69]. NKT cells release Th1-type cytokines including IFNγ and TNF-α as well as the Th2-type cytokines IL-4 and IL-13 [70]. Individual NKT cells are able to produce both Th1- and Th2-type cytokines at the same time following stimulation in vivo [71]. This is unusual because it is possible that Th1 and Th2 antagonize each other. The implications of this observation and mechanisms are unknown. NKT cells appear to be involved in immediate immune responses, tumor rejection, control of autoimmune disease, and immune surveillance [63]. NKT cells may act as effector cells as seen with their cytotoxic activity; they may also act as regulators. The important question concerns how they determine which way to go. The NKT cells may produce either pro- or anti-inflammatory cytokines. This depends on the type of signal they receive. This is probably related to cytokine profiles produced. The cytokine profile is dependent on the type of TCR stimulation the NKT cells receive. The study of NKT cells is an important topic of investigation today and probably will be for some time. It is clear that NKT cells are involved in a number of


1/5/2008 11:47:24 AM

14


pathological conditions and they appear to regulate a number of others. NKT cells appear to have both protective and harmful roles in disease progression of certain allergic and autoimmune disorders and they may modulate viral infections and have a role in tumor growth and progression.

1.2.8

GAMMA/DELTA T LYMPHOCYTES

Gamma/delta T lymphocytes (γδ T cells) are a relatively recent discovery within the T-cell population. It is difficult to categorize them but it is becoming clear they are an important component of host defense and may represent a different parallel immune system component [72]. It is likely that γδ T-cell functions fall somewhere “in-between” the innate and adaptive immune systems. A major characteristic of the γδ T-cell population is that they have a TCR consisting of a γδ heterodimer rather than the more prevalent αβ TCR [73]. γδ T cells make up a small percentage of T cells (1–5%) in peripheral blood and other lymphoid organs. However, they are found in higher concentrations in the skin, gastrointestinal tract, and the genitourinary system [73]. These locations may be related to the types of antigens they encounter and the immunological responses they deliver. γδ T cells may be important in preventing infection with organisms such as Mycoplasma penetrans, an organism capable of causing urethritis and respiratory diseases in immunocompromised individuals [74]. In addition, Mycobacterium tuberculosis has been shown to elicit a γδ T-cell response [75]. γδ T cells may also recognize and express cytoxic activity against certain types of tumors, including both hematopoietic and solid tumors [73]. It has been suggested that γδ T cells recognize ligands, which are different from the short peptides that are detected by αβ T cells in the context of MHC class I or II molecules [76]. At least one subclass of γδ T cells recognizes lipidlike antigens from pathogens. Another functional subtype recognizes stress-inducible MHC-related molecules and a number of other ligands [76]. γδ T cells are active producers of cytokines, which are cytotoxic for many tumor cells. Activated γδ T cells, through cytokine production, may modulate conventional immune responses by acting on macrophages and DCs. It has been shown that γδ T cells function as both activators and inhibitors of immune reactions through surface-bound receptors [73]. Most γδ T cells possess the NKG2D receptor, which may provide a costimulatory signal that is essential for the γδ T-cell response against certain types of tumor cells. Through their interactions, both directly and indirectly, γδ T cells appear to supplement the cellular immune response by recognizing and responding to antigens that may not be detected by the more prevalent αβ T cells. These γδ T cells appear to have an influence on both innate and adaptive responses through patternlike recognition systems, cytoxicity against tumor cells, and providing protection against intracellular pathogens.

1.2.9

DENDRITIC CELLS

DCs have been known since 1973; however, the importance of DCs in both innate and adaptive immunity has been defined more clearly in the past few years. The DCs develop in the bone marrow and are found in the circulating blood and tissues


1/5/2008 11:47:24 AM


15

such as the spleen, lungs, gut mucosa, and other places where they may play a role in immunosurveillance. The DCs develop in the bone marrow from hematopoietic pluripotential stem cells [77]. Precursor DCs are constantly generated in the bone marrow and are released into the peripheral blood. After leaving the bone marrow, the precursor DCs “home” to a number of different tissues where they reside as sentinels waiting to interact with antigen. The precursor DCs express low-density MHC class II antigens and after encountering a proper stimulus differentiate into highly endocytic and phagocytic iDCs [78]. DCs probably make up a heterogeneous population of cells. However, precursor DCs, iDCs, and mature DCs play different roles in the immune system. Precursor DCs circulate in the environment and on contacting a pathogen produce cytokines, that is, γ-interferon, and undergo maturation to iDCs. The iDCs acquire new properties, that is, markedly increased phagocytic and endocytic capabilities that lead to binding antigen by the iDCs and then maturation to mature DCs [78]. The mature DCs have specialized properties (receptors) to bind foreign or effete cells through lectin and Fcγ receptors. Once the antigens enter the mature DCs, they are processed for antigen presentation and the mature DCs become an APC and lose their phagocytic properties. The mature DCs are the only cells capable of activation of naïve T cells and are defined by this characteristic [79]. A variety of different stimuli can initiate DCs maturation including pathogens, damaged tissue-derived antigens, and ultraviolet light. The mature DCs, carrying the antigen, then migrates to the secondary lymphoid tissues [78]. 1.2.9.1

Immature Dendritic Cells

iDCs are activated upon exposure to the so called danger signals, including PAMPs and become actively phagocytic for the infectious agent. As a part of their maturation to mature DCs, the iDCs become less phagocytic but more mobile once the DC has taken up the antigen and begun processing it. Activation and maturation of DCs occur through the NF-κB signaling pathway [80]. The iDC neither provides T-cell stimulation nor cosignaling. 1.2.9.2

Mature Dendritic Cells

After maturation from iDC, the mature DC migrates to the secondary lymphoid tissues where it begins processing the antigenic material. This migration occurs because of the expression of specific chemokine receptors, especially CCR-7. Mature DCs have highly developed antigen-processing cell capabilities and are capable of loading endocytosed antigenic peptides on both MHC class I and II molecules thereby permitting presentation to both CD8+ and CD4+ T lymphocytes [81]. Mature DCs have high-density costimulatory molecules for presenting processed antigen to T cells [79]. Maturation of DCs is associated with the up-regulation of the costimulatory molecules. Costimulatory molecules CD40, CD80, and CD86 enhance the stability of DCs interactions with naïve antigen-specific CD4+ and CD8+ T lymphocytes and the secretion of cytokines such as INFα, IL6, IL-10, and IL-12. The mature DCs are potent activators of T-cell responses. The DCs transmit information about the danger signals to the T cell and help define the T-cell responses [82].


1/5/2008 11:47:25 AM

16


There are two subsets of DCs in the blood based on the expression of CD11c (β2 integrin). The subsets named, myeloid DCs (M-DCs) and lymphoid DCs or plasmacytoid DCs (P-DCs), differ in morphology and expression of markers and function [83]. They do, however, share some surface markers for adhesion, activation, costimulation, and coinhibition. M-DCs express myeloid surface markers, that is, CD13, CD33, and CD11c. The M-DCs also express large numbers of mannose receptors and rapidly take up polysaccharide antigens [84]. The M-DCs readily capture antigen in peripheral tissues by phagocytosis and migrate as immature M-DCs to lymph nodes where stimulation with CD40L (CD40 ligand) induces maturation to mature M-DCs. The M-DCs are potent inducers of both Th1 and Th2 cytokines in naïve CD4+ T lymphocytes. The local microenvironments bias the development of either Th1 or Th2 types of reactions [84]. The P-DCs have morphology similar to plasma cells and are derived from a lymphoid lineage. Instead of myeloid markers, the P-DCs express high levels of CD123 and MHC molecules. CD40L (ligand) causes stimulation of P-DCs and results in DCs maturation. These DCs support Th2 cytokines (primarily). The P-DCs populate T-cell areas of lymph nodes and may have a special ability to recognize self-antigens or viruses [85]. The cell surface receptor CD40 plays an important role in humoral and cellmediated immune responses. CD40 is expressed on many cell types including B cells, epithelial and endothelial cells, and all APC. The ligand for CD40 is CD40L and is a trimeric TNF-α-like molecule. CD40L is expressed primarily on T helper cells [86]. Ligation of CD40 on the surface of the DCs induces maturation that is detected by markedly enhanced T-cell stimulatory capacity. This maturation of the DCs causes it to activate naïve CD8+ cytotoxic T-cells (CTL) that are important in developing immunity against certain pathogens and tumors [86]. The types of T-cell subsets induced by DCs is dependent on several factors including the DCs subset involved, the nature and dose of the antigen, and the types of cytokines present in the microenvironment where the interaction between DCs and pathogen occurs. DCs play an important role in how a host responds to foreign antigens, effete, or other cells that have initiated its maturation. The DCs help direct the T cell to respond—how it should respond, and where to go to respond. The DC provides a number of sequential signals to the responding T cells. The first signal consists of the interaction of the TCR with the specific antigen in the context of the MHC protein on the surface of the DC. This determines the antigenic specificity of the response and triggers the differentiation of naïve CD4+ and CD8+ T cells into T helper and CTL, respectively. This antigen-specific T-cell activation requires the engagement of the TCR/CD3 complex. The antigenic peptide is presented by the MHC and the engagement of appropriate costimulatory reception by costimulatory ligands on the DCs [87]. The DCs also provide the costimulatory signaling that T cells require to respond to antigen. The cosignaling can be either positive or negative. Cosignaling may be provided by a number of different molecules including CD80, CD86, and CD28. The activation and maturation signals may be diverse, but all involve activation of the NF-κB signaling pathway [88]. In the presence of a negative cosignal (coinhibitory) or


1/5/2008 11:47:25 AM


17

in the absence of a positive costimulatory signal, T cells will fail to respond and may not be capable of reacting to that specific antigen in the future. Some pathogens have evolved mechanisms to help evade this component of the innate immune response. These pathogens possess compounds capable of arresting DCs in their immature state where they cannot produce costimulating molecules. Without costimulatory activity, the DCs are unable to completely stimulate T cells to respond [89] and the pathogens to avoid an immune response directed against them. DCs also direct the functional polarization of CD4+ T cells into Th1, Th2, and Treg cells [90]. The nature of the “danger signal” or PAMP defines the DCs response as Th1-, Th2-, or Treg-type responses, which result in the DCs producing certain cytokines to induce T-cell differentiation into Th1, Th2, or Treg CD4+ T lymphocytes [90]. It is unclear whether or not the DCs are restricted to one polarization type or if they are flexible depending on the nature of the stimulus and this microenvironment. The nature of the binding of the stimulating agent (type of PAMP) to certain types of TLRs induces the DC maturation, which results in the development of Th1 T cells [91]. For example, binding of microbial double strand RNA (ds RNA) to TLR3 triggers the formation of the Th1 T cells. Other TLRs associated binding signals produce either Th1 or Th2 types of responses depending on the TLR type and the danger signal. It appears that the nature of the PAMP is important in defining the T-cell response. In general, Th1-type responses are directed to cell-mediated types of responses and the nature of the cytokines produced drives these responses. A Th2 T-cell response may result from antigens of a parasites-inducing type 2 DCs, which go on to produce a Th2 type of response. Th2 responses are usually antibody or humoral immune responses [89,92]. Treg-type T cells are CD4+ T cells that can suppress responses of other T cells and probably play an important role in regulating self-tolerance. Multiple subtypes of Treg cells have been identified and each has its own specific phenotype, cytokine profile, and mechanism of activation for suppressing immune responses. The most frequently described phenotype includes CD25 as a surface marker [93,94]. The Treg cells have been shown to interfere with tumor immunity and a number of parasites are known to induce regulatory DCs that induce Treg responses. For example, a hemagglutin from Bordetella pertusis serves as a ligand for TLR2 and this induces the development of regulatory DCs and ultimately Treg T cells. It is important that immune responses are initiated against foreign substances but immune responses should not be directed at self-antigens. DCs are responsible for the induction of peripheral and central tolerance. A major role of the DCs is to recognize “danger signals” and activate the appropriate response by passing information to T cells through cytokines and chemokines to direct the T-cell response. As expected, cytokines production by DCs is tightly regulated. The DCs possess PRRs that can detect concerned motifs on invading pathogens and distinguish them from self-antigens. There is constant communication between DCs and T cells with information being shared in both directions. The exact mechanisms involved in how DCs and T cells combine to distinguish self from non-self are not understood completely. However, iDCs are involved in the maintenance of tolerance to self-antigens by constantly defining self in the periphery. The iDCs constantly sample different


1/5/2008 11:47:25 AM

18


self-antigens and present them to T cells under noninflammatory conditions permitting the detection of autoreactive T cells. The iDCs may also induce tolerance to self by stimulating naïve CD4+ and CD8+ T cells to differentiate into Treg cells that produce IL-10, which in turn causes these cells to inhibit Th1 T-cell differentiation and suppress CD8+ memory cell responses. Figure 1.2 summarizes the pivotal role of DCs in immunity.

1.2.10 OVERVIEW OF ADAPTIVE IMMUNITY In contrast to innate immunity, adaptive immunity is flexible, specific, and has immunological memory, that is, it can respond more rapidly and vigorously on a second exposure to an antigen. Immunologic memory provides a more powerful response to a repeated exposure to the same foreign substance or antigen. Adaptive immunity is more complex because it provides the ability to respond very specifically. Innate and adaptive immunity responses interact effectively to enhance the body’s defense mechanisms against foreign or damaged host cells. Inherent in both innate and adaptive immune responses are the mechanisms to distinguish self from nonself. The primary blood cell elements of the adaptive immune system are T lymphocytes and B lymphocytes. These T- and B-cells provide the unique specificity for their target antigens by virtue of the antigen-specific receptors expressed on their surfaces. The B- and T-lymphocyte antigen-specific receptors develop by somatic rearrangement of germline gene elements to form the TCR genes and the immunoglobulin receptor genes. This recombination mechanism provides unique antigen receptors capable of recognizing almost any antigen encountered, and provides the specific immunological memory for a rapid, vigorous, and specific response to a later exposure to the same antigen. It is estimated that millions of different antigen receptors may be formed from a collection of a few hundred germline-encoded gene elements. For many years, innate and adaptive immune responses were studied as separate systems because of their different mechanisms of action. However, it is now understood that synergy between the two systems is required to provide adequate immune reactivity against invading pathogens. Innate immune responses, through their barrier and relatively broad types of actions, represent the first line of defense against pathogens. At the time the innate system is getting activated, the adaptive system becomes activated also. The adaptive response becomes evident a few days later because it requires time for sufficient antigen-specific receptors to be generated through clonal expansion/proliferation. There are multiple interactions occurring between the two systems, which results in the coamplification of each respective response and leads to the ultimate destruction and elimination of the invading pathogen.

1.2.11

B LYMPHOCYTES

The primary function of B lymphocytes is the production of antibodies that are specific for a given antigenic component of an invading pathogen. Antibodies are encoded by the heavy (H)- and light (L)-chain immunoglobulin genes. Antibodies may be secreted or cell surface–bound on B lymphocytes. There are five classes of immunoglobulins: IgM, IgG, IgA, IgD, and IgE; and the classification is based on the isotypes of the H chain. B lymphocytes represent roughly 10–15% of the


1/5/2008 11:47:25 AM


FIGURE 1.2

CD40

Ag iDC Maturation

Proinflammatory signals

Migration to secondary lymphoid tissue

Partial summary of the role of dendritic cell in cellular immunity.

CD40L (Th cells )

NK cell

Capture

Ag

Antigen-presenting cells

MDC

CD40

Naïve Th cell CD40L

CD28

CD80/ CD56

Th 2response response

B cells

Ab

Naïve Th T cell

Treg T cells

Th 2 cell

+

IL-12

Th1

+ or – signals to CD4 + Th

Naïve CD4/CD8 T cells

Effector T cells

CTL

Overview of Immunity 19

1/5/2008 11:47:25 AM

20


peripheral blood lymphocyte population and free immunoglobulins make up a considerable proportion of serum proteins. After an encounter with a specific pathogen and an antibody response is generated, the level of specific antibodies to that antigen decreases in serum over a relatively short period of time. However, immunological memory persists in the B-cell population, which is capable of rapid clonal expansion upon reexposure to that same antigen [95]. Protective immunity for a specific antigen requires cooperation between B and T lymphocytes. In many instances, helper T-cell interaction is required for the development of high-affinity antibodies and complete protection. For naïve B lymphocytes to undergo proliferation and differentiation in response to most antigens, they require stimulation by a CD4+ T helper cell with the same antigenic specificity. B lymphocytes are capable of antigen presentation to T cells through their surface MHC class II proteins [96]. Antibodies recognize the tertiary structure of proteins and react with specific epitopes in the antigen structure [97]. During an immune response, immunoglobulin formation may undergo switching from one isotype of immunoglobulin to another, usually from IgM to IgG and IgA or IgE. This switching requires additional genetic recombination between the same variable region genes and new H-chain isotope genes. As the humoral immune response continues, antibodies with higher affinity for the antigen develops. Competition for antigen provides a selective advantage to B lymphocytes with the highest affinity for antigen.

1.2.12

T LYMPHOCYTES

Whereas B lymphocyte products recognize extracellular pathogens, T lymphocytes are adept at identifying and destroying cells that have been infected by intracellular pathogens. For T cells to recognize antigenic peptides, the peptide must be presented in the context of cell surface MHC class I or class II proteins [98]. In other words, T cells can only recognize molecular complexes consisting of the antigenic peptide and a self-structure, that is, the MHC. Depending on whether the antigenic peptide has been synthesized within the host cell or ingested by the cell and modified by proteolytic digestion, either MHC class I or class II proteins are required [99]. Proteins of the MHC are intimately tied to T-lymphocyte responses and recognition of antigenic peptides. The MHC class I proteins consist of three HLA classes: HLA-A, HLA-B, and HLA-C with hundreds of allelic variants of each. Structural studies have shown that class I molecules exist as cell surface heterodimers with a polytransmembrane α-chain associated (noncovalently) with a nonpolymorphic β2 microglobulin protein [99]. The protein chains are folded in such a way as to form a physical groove capable of binding up to an 11 amino acid long peptide. Antigenic proteins are degraded by proteolytic enzymes to about this size for binding to the MHC class I proteins for antigenic presentation. Antigenic peptides are bound in the groove of the HLA molecule and expressed to the cell surface for presentation to initiate a T-cell response [99]. The large number of HLA class I alleles reflects structural polymorphism, which adds to the number of antigenic peptides that can be recognized. Most humans are


1/5/2008 11:47:26 AM


21

heterozygous for HLA, further increasing the numbers of antigenic polypeptides bound and capable of activating T cells [100]. There are three major groups of MHC class II proteins, HLA-DR, HLA-DQ, and HLA-DP, each with large numbers of alleles. Class II proteins are also folded in such a way as to form a groove for binding peptides for presentation as a complex consisting of the protein fragment—HLA structure. Class II proteins consist of two polypeptide chains, which are MHC-encoded transmembrane proteins [101]. As mentioned earlier, the antigenic peptides bound to class II proteins are derived from exogenous antigens taken up by APCs and are degraded into peptides of a size appropriate for loading in the class II protein groove. The phagocytosed antigens were degraded by proteolytic enzymes found in the lysosomes of the APC and further processed by specialized proteins in the cytoplasm to generate peptides of the correct length for binding [101]. As with the MHC class I proteins, the large repertoire of the peptide-binding class II molecule is generated through polymorphisms of the class II proteins where there are multiple alleles of each HLA type. Once again, class I and class II HLA proteins differ in the types of peptides recognized and where and how the antigenic peptides are generated. The thymus is an organ dedicated to T-cell development. T cells originate in the bone marrow as progenitors and circulate in the blood stream before eventually homing to the thymus. The particular environment in the thymus provides the optimal milieu for thymic lineage development [102]. It is likely that interaction with the thymic stroma provides the signals required for the thymic progenitor cells to undergo proliferation and differentiation into mature naïve T cells [102]. This process is tightly regulated and is mediated by various transcription factors, cytokines, chemokines, and one or more selectins. T lymphocytes make up the majority of lymphocytes in peripheral blood and are most readily defined by the expression of TCR molecules on their surface. The αβ TCR molecules recognize specific peptide antigens that are presented in the context of the MHC class I or class II proteins (in the form of a complex). T cells expressing αβ molecules differentiate into different subsets including the CD4+ T cells and the CD8+ T cells. The CD4+ T-cell subsets are active as regulators of cellular and humoral immune responses. The other subset, CD8+ T cells, is cytotoxic for cells infected with intracellular pathogens. T-lymphocyte receptors are different from the B-lymphocyte immunoglobulin receptors in that they are never secreted and are able to recognize peptides produced after proteolytic breakdown of antigens as opposed to B-cell receptors that react to native proteins [103]. TCRs recognize the primary amino acid structure of the protein antigen. TCRs recognize antigenic peptides only when they are presented as cell surface–bound complexes with MHC class I or II proteins. Each T cell bears a TCR with a single antigenic specificity and these cells provide recognition for a very large number of possible pathogens. T-lymphocyte activation through the TCR is an important step in the initiation of an adaptive immune response. TCR activation requires two interactions [99]. One is the interaction between the TCR and the peptide MHC complex, which gives a partial signal for T-cell activation. Full activation requires both the TCR-peptide-MHC binding and the interaction with a costimulatory molecule,


1/5/2008 11:47:26 AM

22


CD28, on the T cell and CD80 or CD86 present on the APC [99]. This second signal stimulates proliferation and differentiation of the T cell. If T cells do not receive the second signal they may become unresponsive and possibly anergic. There is considerable cross talk between T- and B-cells in an adaptive immune response. For proliferation and differentiation to occur, naïve B cells must be stimulated by a particular type of helper T cell, the CD4+ T cell. Moreover, the B and the CD4+ helper T cells must have receptors that are specific for epitopes present on the same antigenic molecule. The complex interaction between T helper cells and B cells (with matching specificities for a pathogen-specific antigen) and a second signal to the T cell (possibly provided by the B cell) results in the proliferation and differentiation of both B- and T-cells and ultimately in an adaptive immune response. T cells are divided into a number of subsets based on their migration patterns and functional abilities. The naïve T lymphocytes tend to circulate between the blood and lymph nodes in response to the homing receptor l-selectin [104]. Recirculation of naïve T cells allow them to move in and out of areas of the body where they have the best chance of detecting a pathogen bearing their specific antigen receptor [104]. At least two types of memory T cells are active in adaptive immunity. One subtype, the effector memory cell, is short-lived and aggressively migrates to the site of the target tissue to destroy the pathogen. The second subset, called central memory cells, serves a role in immunologic memory and has migratory patterns that place them in environments where pathogens may enter [104]. Antigenic stimulation of these memory cells leads to a rapid proliferative response leading to the production of both effector and central memory T cells. There appears to be a tendency for memory T cells to migrate back to the tissue where they first encountered a specific antigen. This appears to be controlled by specific homing receptors on the surface of memory T cells. As mentioned earlier, αβ T cells, while in the thymus, differentiate into T-cell subpopulations expressing CD4 or CD8 cell surface markers. These cell populations were described first as phenotypic markers and their functions were described later. Originally, these T cells were considered to be helper cells (CD4) and suppressor cells (CD8) but later the CD8 cells were identified as cytotoxic T cells [105]. These associations are not absolute, since some CD4+ T cells may also have cytotoxic properties. CD4+ molecules and CD8+ molecules serve as coreceptors in the interaction between the T cells and APC. The CD4 molecules expressed on the surface of T cells bind to class II molecules expressed on the surface of APCs and serve to stabilize the interaction between that particular T cell and the APC. CD8 molecules, however, bind to class I molecules expressed on the surface of APCs and serve to stabilize the interaction between CD8 T cells and APCs. When naïve CD4+ or CD8+ T cells are activated by APC, they undergo differentiation into distinct subsets with different functions. The effector functions of the T-cell subsets are determined by the nature of the costimulatory signals given and the cytokines secreted [106]. There are two main subsets of CD4+ T cells generated or determined by the cytokines secreted by the APC, Th1, and Th2. The Th1 subsets are generated by APCs secreting IL-2. The T cells differentiate into effector cells producing high levels of IFN-γ and IL-2. This subset, Th1, generally supports cell-mediated immunity by producing cytokines INF-γ and TNF-β


1/5/2008 11:47:26 AM


23

that are efficient in activating macrophages and cytotoxic T cells [107]. In contrast, naïve CD4+ T cells activated by IL-4 stimulated DCs differentiate into effector T cells designated Th2. The Th2 subset actively supports the development of humoral or antibody responses [107]. Th2 lymphocytes secrete IL-4, IL-5, IL-9, and IL-13, which in turn are efficient at stimulating B lymphocytes to differentiate into antibody-forming cells (particularly IgE) and actively secrete antibody. Generally, most immune responses show a combination of both features of Th1 and Th2 pathways and a prolonged immunization process may lead to one pathway becoming the most dominant. To a certain extent, Th1 and Th2 subsets secrete cytokines that can suppress one another, that is, Th1 secrete cytokines that can suppress Th2 responses and Th2 cells produce cytokines that can suppress Th1 responses. Another family of CD4+ T cells called Treg was recently shown to suppress the responses of other T cells [93]. It is likely the Treg cells play a role in regulating self-tolerance but may have a harmful effect on tumor immunity. Several subsets of Treg cells have been reported and each has a distinct surface phenotype, cytokine profile, and mechanism of action for suppressing immune responses. Initially, high CD25 expression was used to identify the majority of human Treg cells. The CD4+ cells with the greatest regulatory activity had high levels of CD25 (i.e., CD4+ CD25 high T cells). A considerable number of other surface markers have been shown on Treg cells but expression is not as great or as consistent as CD25 [108]. More recently, the intracellular protein FOXP3 has been identified as a key molecule involved in driving the activity of Treg and now serves as a marker to enumerate these cells.

1.2.13 COMMENTS This chapter serves as a background and provides a broad overview for the remainder of the chapters.

REFERENCES 1. Blach-Olszweska, Z., Innate immunity: cells, receptors and signaling pathways, Arch. Immunol. Ther. Exp., 53, 245, 2005. 2. Janeway, C.A. Jr., Medzhitov, R., Innate immune recognition, Ann. Rev. Immunol., 20, 197, 2002. 3. Banchereau, J., Steinman, R.M., Dendritic cells and the control of immunity, Nature, 392, 245, 1998. 4. Ganz, T., Defensins: antimicrobial peptides of innate immunity, Nat. Rev. Immunol., 3, 710, 2003. 5. Yang, D., Chertov, O., Bykovskia, S.N., Chen, Q., Buffo, M.J., Shogan, J., Anderson, M., Schroeder, J.M., Wang, J.M., Howard, O.M., Oppenheim, J.J., β-defensins: linking innate and adaptive immunity through dendritic and T cell CCR6, Science, 286, 525, 1999. 6. De Smet, K., Contreras, R., Human antimicrobial peptides: defensins, cathelicidins and histantins, Biotechnol. Lett., 18, 1337, 2005. 7. Pazgiera, M., Hoover, D.M., Yang, D., Lu, W., Lubkowski, J., Human β-defensins, Cell. Mol. Life Sci., 63, 1294, 2006.


1/5/2008 11:47:26 AM

24


8. Boniotto, M., Jordan, W.J., Eskdale, J., Tossi, A., Antcheva, N., Crovella, S., Connell, N.D., Human β-defensin 2 induces a vigorous cytokine response in peripheral blood mononuclear cells, Antimicrob. Agents. Chemother., 50, 1433, 2006. 9. Tjabringa, C.S., Ninaber, D.K., Drijfhout, J.W., Rabe, K.F., Hiemstra, P.S., Human cathelicidin LL-37 is a chemoattractant for eosinophils and neutrophils that acts via formyl-peptide receptors, Int. Arch. Allergy Immunol., 140, 103, 2006. 10. Castagnola, M., Inzitari, R., Rossetti, D.V., Olmi, C., Cabras, T., Piras, V., Nicolussi, P., Sanna, M.T., Pellegrini, M., Giardina, B., Messana, I., A cascade of 24 histantins (histatin 3 fragments) in human saliva: suggestions for a pre-secretory sequential cleavage pathway, J. Biol. Chem., 279, 41436, 2004. 11. Schittek, B., Hipfel, R., Sauer, B., Bauer, J., Stevanovic, S., Schrile, M., Schroeder, K., Blin, N., Meier, F., Rassner, G., Garbe, C., Dermicidin: a novel human antibiotic peptide secreted by sweat glands, Nat. Immunol., 2, 1133, 2001. 12. Madsen, P., Rasmussen, H.H., Leffers, H., Honore, B., Dejgaard, K., Olsen, E., Kill, J., Walbum, E., Andersen, A.H., Basse, B., Molecular cloning, occurrence and expression of a novel partially secreted protein “psoriasin” that is highly up-regulated in psoriatic skin, J. Invest. Dermatol., 97, 701, 1991. 13. Rus, H., Cudrici, C., Niculescu, F., The role of the complement system in innate immunity, Immunol. Res., 33, 103, 2005. 14. Fujita, T., Endo, Y., Nonaka, M., Primitive complement system—recognition and activation, Mol. Immunol., 41, 103, 2004. 15. Petersen, S.V., Thiel, S., Jensen, L., Vorup-Jensen, T., Koch, C., Jensenius, J.C., Control of the classical and the MBL pathway of complement activation, Mol. Immunol., 37, 803, 2000. 16. Xu, Y., Narayana, S.V., Volanakis, J.E., Structural biology of the alternative pathway convertase, Immunol. Rev., 180, 123, 2001. 17. Frank, M.M., Complement system, in Samter’s Immunologic Diesease, Frank, M.M., Claman, H.N., Unanue, E.R., Eds., Boston, MA, Little, Brown & Company, 1995, 331p. 18. Baumgarth, N., Tung, J.W., Herzenberg, L.A., Inherent specificities in natural antibodies: a key to immune defense against pathogen invasion, Springer Semin. Immunopathol., 26, 347, 2005. 19. Brändlein, S., Vollmers, H.P., Natural IgM antibodies, the ignored weapons in tumor immunity, Histol. Histopathol., 19, 897, 2004. 20. Medzhitov, R., Janeway, C.A. Jr., Innate immunity: the virtues of a non-clonal system of recognition, Cell, 91, 295, 1997. 21. Sagaert, X., DeWolf-Peeters, C., Classification of B-cells according to their differentiation status, their micro-anatomical localization and their developmental lineage, Immunol. Lett., 90, 179, 2003. 22. Christofaro, P., Opal, S.M., Role of toll-like receptors in infection and immunity: clinical implications, Drugs, 66, 15, 2006. 23. Kaisho, T., Akira, S., Toll-like receptor function and signaling, J. Allergy Clin. Immunol., 117, 979, 2006. 24. Beutler, B., Hoebe, K., Du, X., Ulevitch, R.J., How we detect microbes and respond to them: the toll-like receptors and their transducers, J. Leukocyte Biol., 74, 479, 2003. 25. Means, T.K., Golenbock, D.T., Fenton, M.J., The biology of Toll-like receptors, Cytokine Growth Factor Rev., 11, 219, 2000. 26. Akira, S., Takeda, K., Toll-Like receptor signaling, Nat. Rev. Immunol., 4, 499, 2004. 27. Freeman, G.J., Gray, G.S., Gimmi, C.D., Lombard, D.B., Zhou, L.J., White, M., Fingeroth, J.D., Gribben, J.G., Nadler, L.M., Structure, expression and T cell costimulatory activity of the murine homologue of the human B lymphocyte activation antigen B7, J. Exp. Med., 174, 625, 1991.


1/5/2008 11:47:26 AM


25

28. Baume, C.M., Weissman, I.L., Tsukamoto, A.S., Buckle, A.M., Peault, B., Isolation of a candidate human hematopoietic stem-cell population, Proc. Natl. Acad. Sci. USA, 89, 2804, 1992. 29. Athens, J., Haab, O.P., Raab, S.O., Mauer, A.M., Ashenbrucker, H., Cartwright, G.E., Wintrobe, M.M., Leukokinetic studies. IV. The total blood, circulating and marginal granulocyte pools and the granulocyte turnover rate in normal subjects, J. Clin. Invest., 40, 989, 1961. 30. Butcher, E.C., Leukocyte-endothelial cell recognition: three (or more) steps to specificity and activity and diversity, Cell, 67, 1033, 1991. 31. Ley, K., Integration of inflammatory signals by rolling neutrophils, Immunol. Rev., 186, 8, 2002. 32. Doerfler, M.E., Danner, R.L., Shelhamer, J.H., Parrillo, J.E., Bacterial lipopolysaccharides prime human neutrophils for enhanced production of leukotriene B4, J. Clin. Invest., 83, 970, 1989. 33. Lawrence, M.B., Springer, T.A., Leukocytes roll on a selectin at physiologic flow rates: distinction from and prerequisite for adhesion through integrins, Cell, 65, 859, 1991. 34. Rossi, D., Zlotnik, A., The biology of chemokines and their receptors, Annu. Rev. Immunol., 18, 217, 2000. 35. Joiner, K.A., Brown, E.J., Frank, M.M., Complement and bacteria: chemistry and biology in host defense, Annu. Rev. Immunol., 2, 461, 1984. 36. Unkeless, J.C., Shen, Z., Liu, C.W., DeBeus, E., Function of human Fc gamma RIIA and Fc gamma RIIIB, Semin. Immunol., 7, 37, 1995. 37. Stossel, T.P., Phagocytosis, Prog. Clin. Biol. Research, 13, 87, 1977. 38. Klebanoff, S.J., Myeloperoxidase: friend or foe, J. Leukoc. Biol., 77, 598, 2005. 39. Cohn, Z.A., Hirsch, J.G., Degranulation of polymorphonuclear leukocytes following phagocytosis of microorganisms, J. Exp. Med., 112, 1005, 1960. 40. Spitznagel, J.K., Dalldorf, F.G., Leffell, M.S., Folds, J.D., Welsh, I.R., Clooney, M.H. et al., Character of azurophil and specific granules purified from human polymorphonuclear leukocytes, Lab Invest., 30, 774, 1974. 41. Ganz, T., Defensins in the urinary track and other tissues, Infect. Dis., 183, S41, 2001. 42. Klebanoff, S.J., Waltersdorph, A.M., Prooxidant activity of transferrin and lactoferrin, J. Exp. Med., 172, 1293, 1990. 43. Gouwy, M., Struyf, S., Proost, P., van Damme, J., Synergy in cytokine and chemokine networks amplifies the inflammatory response, Cytokine Growth Factor Rev., 16, 561, 2005. 44. Borish, L.G., Steinke, J.W., 2. Cytokines and chemokines, J. Allergy Clin. Immunol., 111, S460, 2003. 45. Sigal, L.H., Basic science for the clinician 33: interleukins of current clinical relevance (part 1), J. Clin. Rheumatol., 10, 353, 2004. 46. Charo, I.F., Ransohoff, R.M., Mechanisms of disease: the many roles of chemokines and chemokine receptors in inflammation, N. Engl. J. Med., 354, 610, 2006. 47. Guimond, M., Fry, T., Mackall, C., Cytokine signals in T-cell homeostatis, J. Immunother., 28, 289, 2005. 48. Romagnani, P., From basic science to clinical practice: use of cytokines and chemokines as therapeutic reagents in renal diseases, J. Nephrol., 18, 229, 2005. 49. Oppenheim, J., Feldman, M., in Cytokine References, Oppenheim, J., Feldman, M., Durum, S.K., Hirano, T., Vicek, J., Nicola, N., Eds., San Diego, CA, Academic Press, 2001, pp. 3–20. 50. Bentley, B., Cerami, A., The biology of cachectin/TNFα-primary mediator of the host response, Rev. Immunol., 7, 625, 1989. 51. Steinke, J.W., Borish, L., 3. Cytokines and chemokines, J. Allergy Clin. Immunol., 117, S441, 2006.


1/5/2008 11:47:27 AM

26


52. O’Conner, G.M., Hart, O.M., Gardiner, C.M., Putting the natural killer cell in its place, Immunology, 117, 1, 2005. 53. Raulet, D.H., Interplay of natural killer cells and their receptor with the adaptive immune response, Nat. Immunol., 5, 996, 2004. 54. Jonges, L.E., Albertsson, P., vanVlierberghe, R.L., Ensink, N.G., Johansson, B.R., van de Velde, C.J., Fleuren, G.J., Nannmark, U., Kuppen, P.J.K., The phenotypic heterogeneity of human natural killer cells: presence of at least 48 different subsets in the peripheral blood, Scand. J. Immunol., 53, 103, 2001. 55. Orange, J.S., Ballas, Z.K., Natural killer cells in human health and disease, Clin. Immunol., 118, 1, 2006. 56. Cooper, M.A., Fehniger, T.A., Caligiuri, M.A., The biology of human naturalkiller-cell subsets, Trends Immunol., 22, 633, 2001. 57. Sigal, L.N., Molecular biology and immunology for clinicians 22: natural killer cell receptors and activation mechanisms, J. Clin. Rheumatol., 9, 55, 2003. 58. Biron, C.A., Nguyen, K.B., Dien, B.C., Counsens, L.P., Salazar-Mather, T.P., Natural killer cells in antiviral defense: function and regulation by innate cytokines, Ann. Rev. Immunol., 17, 189, 1999. 59. Snyder, M.R., Weyand, C.M., Goronzy, J.J., The double life of NK receptors: stimulation or co-stimulation? Trends Immunol., 25, 25, 2004. 60. Orange, J.S., Brodeur, S.R., Jain, A., Bonilla, F.A., Schneider, L.C., Kretschmer, R., Nurko, S., Rassmussen, W.L., Köhler, J.R., Gellis, S.E., Ferguson, B.M., Stominger, J.L., Zonana, J., Ramesh, N., Ballas, Z.K., Geha, R.S., Deficient natural killer cell cytotoxicity in patients with IKK-γ/NEMO mutations, J. Clin. Invest., 109, 1501, 2002. 61. Orange, J.S., Human natural killer cell deficiencies and susceptibility to infection, Microbes Infect., 4, 1545, 2002. 62. Kronenberg, M., Toward understanding of NKT cell biology: progress and paradoxes, Annu. Rev. Immunol., 26, 877, 2005. 63. Jameson, J., Witherden, D., Havran, W., T cell effector mechanisms: γδ and CD1drestricted subsets, Curr. Opin. Immunol., 15, 349, 2003. 64. Kawano, T., Cui, J., Koezuka, Y., Toura, I., Kaneko, Y., Motoki, K., Ueno, H., Nakagawa, R., Sato, H., Kondo, E., Koseki, H., Taniguchi, M., CD1d-restricted and TCR-mediated activation of Vα14NKT cells by glycosylceramides, Science, 278, 1626, 1997. 65. Solomon, M., Sarvetnick, N., The pathogenesis of diabetes in the NOD mouse, Adv. Immunol., 84, 239, 2004. 66. Zhou, D., Mattner, J., Cantu, C. III., Schrantz, N., Yin, N., Gao, Y., Sagiv, Y., Hudspeth, K., Wu, Y.-P., Yamashita, T., Teneberg, S., Wang, D., Proia, R.L., Levery, S.B., Savage, P.B., Teyton, L., Bendelac, A., Lysosomal glycosphingolipid recognition by NKT cells, Science, 306, 1786, 2004. 67. Gumperz, J.E., Miyake, S., Yamamura, T., Brenner, M.B., Functionally distinct subsets of CD1d-restricted natural killer T cells revealed by CD1d tetramer staining, J. Exp. Med., 195, 625, 2002. 68. Brigh, M., Brenner, M.B., CD1d: antigen presentation and T cell function, Annu. Rev. Immunol., 22, 817, 2004. 69. Godfrey, D.I., Hammond, K.J., Poulton, L.D., Smyth, M.J., Baxter, A.G., NKT cells: facts, functions and fallacies, Immunol. Today, 21, 573, 2000. 70. Smyth, M.J., Godfrey, D.T., NKT cells and tumor immunity—a double-edged sword, Nat. Immunol., 1, 459, 2000. 71. Matsuda, J.L., Naidenko, O.V., Gapin, L., Tracking the response of natural killer T cells to a glycolipid antigen using CD1d tetramers, J. Exp. Med., 192, 741, 2000. 72. Segal, L.H., Basic science for the clinician 35: CD1, invariant NKT (iNKT) cells, and γδ T-cells, J. Clin. Rheumatol., 11, 336, 2005.


1/5/2008 11:47:27 AM


27

73. Champagne, E., Martinez, L.O., Vantourant, P., Collet, X., Barbaras, R., Role of apolipoproteins in γδ and NKT cell-mediated innate immunity, Immunol. Res., 3, 241, 2005. 74. Born, W.K., Reardon, C.L., O’Brien, R.L., The function of γδ T cells in innate immunity, Curr. Opin. Immunol., 18, 31, 2006. 75. Guperz, J.E., Brenner, M.B., CD1-specific T cells in microbial immunity, Curr. Opin. Immunol., 13, 471, 2001. 76. Holtmeir, W., Kabelitz, D., Gamma/delta T cells link innate and adaptive immune responses, Chem. Immunol. Allergy, 86, 151, 2005. 77. Schuurhuis, D.H., Fu, N., Ossendorp, F., Melief, C.J.M., Ins and outs of dendritic cells, Int. Arch. Allergy Immunol., 140, 53, 2006. 78. Chain, B.M., Current issues in antigen presentation—focus on the dendritic cell, Immunol. Lett., 89, 237, 2003. 79. Banchereau, J., Steinman, R.M., Dendritic cells and the control of immunity, Nature, 392, 245, 1998. 80. Guermonprez, P., Valladeau, J., Zitvogel, L., Thery, C., Amigorena, S., Antigen presentation and T-cell stimulation of dendritic cells, Annual Rev. Immunol., 20, 621, 2002. 81. Adams, S., O’Neill, B., Recent advances in dendritic cell biology, J. Clin. Immunol., 25, 177, 2005. 82. Kapsenberg, M.L., Dendritic-cell control of pathogen-driven T-cell polarization, Nat. Rev. Immunol., 3, 984, 2003. 83. Dallal, R.M., Lotze, M.T., The dendritic cell and human cancer vaccines, Curr. Opin. Immunol., 12, 583, 2000. 84. Grouard, G., Rissoan, M.C., Filgueira, L., Durand, I., Banchereau, J., Liu, Y.J., The enigmatic plasmacytoid T-cells develop into dendritic cells with interleukin (IL)-3 and CD40 ligand, J. Exp. Med., 185, 1101, 1997. 85. Banchereau, J., Pulendran, B., Steinman, R., Palucka, K., Will the making of plasmacytoid dendritic cells in vitro help unravel their mysteries? J. Exp. Med., 192, F39, 2000. 86. VanKooten, C., Banchereau, J., Functions of CD40 on B cells, dendritic cells and other cells, Curr. Opin. Immunol., 9, 330, 1997. 87. Baxter, A.G., Hodgkin, P.D., Activation rules: the two signal theories of immune activation, Nat. Rev. Immunol., 2, 439, 2002. 88. Bonizzi, G., Karin, M., The two NF-κB activation pathways and their role in innate and adaptive immunity, Trends Immunol., 25, 280, 2004. 89. DeJong, E.C., Vieira, P.C., Kalinski, P., Schuitemaker, J.H.N., Tanaka, Y., Wierenga, E.A., Yazdanbakhsh, M., Kapsenberg, M.L., Microbioal compounds selectively induce Th1 cell-promoting or Th2 cell-promoting dendritic cells in vitro with diverse Th cellpolarizing signals, J. Immunol., 168, 1704, 2002. 90. Agrawal, S., Agrawal, A., Doughty, B., Gerwitz, A., Blenis, J., vanDyke, T., Puledndran, B., Cutting edge: different toll-like receptor agonists instruct dendritic cells to induce distinct Th responses via differential modulation of extracellular signal-regulated kinasemitogen-activated protein kinase and c-fos, J. Immunol., 171, 4984, 2003. 91. Alexopoulou, L., Holt, A.C., Medzhitov, R., Flavell, R.A., Recognition of doublestranded RNA and activation of NF-κB by toll-like receptor 3, Nature, 413, 732, 2001. 92. Whelan, M., Harnett, M.M., Houston, K.M., Patel, V., Harnett, W., Rigley, K.P., A filarial nematode-secreted product signals dendritic cells to acquire a phenotype that derives development of Th2 cells, J. Immunol., 164, 6453, 2000. 93. Sigal, L.H., Basic science for the clinician 32: T-cells with regulatory function, J. Clin. Rheumatol., 11, 286, 2005. 94. D’Ambrosio, D., Regulatory T cells: how do they find their space in the immunological arena? Semin. Cancer Biol., 16, 91, 2006.


1/5/2008 11:47:27 AM

28


95. Cooper, M.D., Alder, M.N., The evolution of adaptive immune systems, Cell, 124, 815, 2006. 96. Delves, P.J., Roitt, I.M., Advances in immunology: the immune system—first of two parts, NEJM, 343, 37, 2000. 97. Garcia, K.C., Teyton, L., Wilson, I.A., Structural basis of T-cell recognition, Annu. Rev. Immunol., 17, 369, 1999. 98. McCullough, K.C., Summerfield, A., Basic concepts of immune response and defense development, ILAR J., 46, 230, 2005. 99. Alam, R., Gorska, M., 3. Lymphocytes, J. Allergy Clin. Immunol., 111, S476, 2003. 100. Groothuis, T., Neefies, J., Ins and outs of intracellular peptides and antigen presentation by MHC class I molecules, Curr. Top. Microbiol. Immunol., 300, 127, 2005. 101. Jones, E.Y., Fugger, L., Strominger, J.L., Siebold, C., MHC class II proteins and diseases: a structural perspective, Nat. Rev. Immunol., 6, 271, 2006. 102. Sebzda, E., Mariathassan, S., Ohteki, T., Jones, R., Bachmann, M.F., Ohashi, P.S., Selection of T cell repertoire, Annu. Rev. Immunol., 17, 829, 1999. 103. Nemazee, D., Receptor selection in B and T lymphocytes, Annu. Rev. Immunol., 18, 19, 2000. 104. Obhrai, J.S., Oberbarnscheidt, M.H., Hand, T.W., Diggs, L., Chalasani, G., Lakkis, F.G., Effector T cell differentiation and memory T cell maintenance outside secondary lymphoid organs, J. Immunol., 176, 4051, 2006. 105. Castellino, F., Germain, R.N., Cooperation between CD4+ and CD8+ T cells: when, where and how, Annu. Rev. Immunol., 24, 519, 2006. 106. Shortman, K., Liu, Y.J., Mouse and human dendritic cell subtypes, Nat. Rev. Immunol., 2, 151, 2002. 107. Neurath, M.F., Finotto, S., Glimcher, L.H., The role of Th1/Th2 polarization in mucosal immunity, Nat. Med., 8, 567, 2002. 108. Graca, L., Silva-Santor, B., Coutinho, A., The blind-spot of regulatory T cells, Eur. J. Immunol., 36, 802, 2006. 109. Seeleen, M., Roos, A., Daha, M.R., J. Nephrol. 18, 642–653, 2005.


1/5/2008 11:47:27 AM

of 2 Statistics Immunological Testing Albert D. Donnenberg CONTENTS 2.1 Overview ......................................................................................................... 30 2.2 Exploratory Data Analysis in the Computer Age ........................................... 30 2.2.1 The Box Plot ........................................................................................ 30 2.2.2 Transformations in Exploratory Data Analysis ................................... 31 2.3 Estimates of Data Location and Dispersion.................................................... 32 2.3.1 Data Location ...................................................................................... 32 2.3.2 Data Dispersion ...................................................................................34 2.3.3 Data Sampling ..................................................................................... 38 2.4 Effect of Sample Size on Parametric Summary Statistics .............................. 39 2.5 Standard Deviations, Standard Errors, and When to Use Them ....................40 2.6 Assumptions of Confirmatory Tests ............................................................... 41 2.6.1 A Word about the Null Hypothesis ..................................................... 42 2.6.2 A Word about Statistical Significance ................................................. 43 2.6.3 Sensitivity and Specificity: Positive and Negative Predictive Values ..... 43 2.6.4 Precision and Accuracy ....................................................................... 45 2.6.5 Statistics and Experimental Design..................................................... 47 2.6.6 A Word about Nonparametric Statistics .............................................. 48 2.6.7 Graphic Representation of Data .......................................................... 48 2.6.7.1 Words of Wisdom Concerning Data Graphics ..................... 48 2.6.7.2 Practical Advice on Data Presentation.................................. 49 2.7 Three Case Studies ......................................................................................... 50 2.7.1 Case I: Thymidine Uptake Data .......................................................... 50 2.7.2 Case II: T-Cell Receptor Heterogeneity as Measured by the v-Beta Distribution ................................................................... 52 2.7.3 Case III: Linear Regression and Correlation—Peripheral Blood CD34 Counts Predict the CD34 Dose Harvested by Leukapheresis ................................................................................. 55 2.8 Caveats and Handy Facts ................................................................................60 2.9 Some Handy Properties of Logs Adapted from Tukey ...................................60 2.10 Presenting Data That Have Been Log Transformed ....................................... 61 2.11 Closing Remarks ............................................................................................. 61 Acknowledgments .................................................................................................... 62 References ................................................................................................................ 62 29


11/28/2007 5:50:24 PM

30


2.1

OVERVIEW

Lord Kelvin* famously said, “Until you can measure something and express it in numbers, you have only the beginning of understanding.” With few exceptions, interpreting immunological assays are all about interpreting numbers, and this can be aided (or not) by the application of statistical methods. This chapter is intended to help students of immunology, who have already had some exposure to statistics, navigate the most common statistical methods that are applied to tests of immunity. To quote the humorist Evan Esar, a statistician is one “who believes figures don’t lie, but admits than under analysis some of them won’t stand up either.” By understanding a few basic statistical methods and avoiding the most common pitfalls of data analysis, the student of immunology increases the odds that his or her figures will, in fact, stand up. Jim Deacon of the University of Edinburgh cites an unnamed Cambridge professor’s take on statistics in Biology: In our Department we have a long corridor with a notice board at one end. I draw a histogram of my results, pin it to the notice board, then walk to the other end of the corridor. If I can still see a difference between the treatments then it’s significant.

The don was advocating a rudimentary form of something that the great statistician and teacher John Tukey called exploratory data analysis (EDA) [1]. In our quest to understand our data, EDA is only a beginning, a method to discern trends and sniff out possible sources of variability without making prior assumptions about the data. Tukey drew a distinction between exploratory and confirmatory data analyses. The latter draws on a rich body of statistical methodology, which in the words of Tukey “[are] principles and procedures to look at a sample, and at what the sample has told us about the population from which it came, and assess the precision with which our inference from sample to population is made.” Tukey advocated that exploratory and confirmatory data analyses proceed side by side.

2.2 EXPLORATORY DATA ANALYSIS IN THE COMPUTER AGE The desktop computer did not exist when John Tukey wrote his seminal tract on EDA. Most of the methods that he invented or promoted were designed to be performed with a pencil, a ruler, and graph paper. Although this must have been somewhat cumbersome, EDA techniques are now implemented in most statistical packages. SYSTAT (Systat Software, Inc., San Jose, California), which I have used for the graphics and analyses in this chapter, has a powerful suite of EDA and graphic tools.

2.2.1

THE BOX PLOT

Figure 2.1 is just what the don ordered. It is a dot plot of reciprocal antibody titers in nine healthy subjects before and one week after booster immunization with tetanus toxoid. * William Thomson (1824–1907), First Baron Kelvin, who among other notable achievements gave us the concept of absolute zero, was fond of such pronouncements. He also said, “In science there is only physics, all the rest is only stamp collecting” and “Large increases in cost with questionable increases in performance can only be tolerated in race horses and women.”


11/28/2007 5:50:25 PM

Statistics of Immunological Testing

31

Reciprocal antibody titer

150,000

100,000

50,000

0 Pre

Post

Immunization status

FIGURE 2.1 Dot plot of reciprocal antibody titers in nine subjects before and one week after immunization with tetanus toxoid vaccine.

It does not pass the don’s test when I step to the back of my less than commodious office and look at the data on my computer screen. What I see is a lot of overlapping dots and a single dot in the pregroup and several dots in the postgroup that are larger than the rest of the values. Did the immunization work? Perhaps not. Figure 2.2 shows the same data displayed using one of the most powerful tools of EDA, the box plot. Box plots display the sample range, median, and the spread of the central 50% of the data surrounding the median. Tukey saw the box as a hinge turned on its side. The outer bounds of the hinge give the location of the central 50% of the data (known as the hinge spread); where the two leaves of the hinge join (the waist) is the sample median (visible in the postgroup). The whiskers (another Tukey coinage) show the range (location of the smallest and largest values), exclusive of outliers, which are indicated by circles (explained in the figure legend). What one sees in the box plot is quite different from the raw dot plot. The median value of the postgroup is higher than that of the pregroup, which on this scale appears to be near the origin. We also notice that the data is not symmetrically distributed, but is quite skewed toward high values. In the pregroup, the first and second quartile are smashed against the origin, and the postgroup has a short whisker below the second quartile, and a long whisker above the third. Both the pre- and postgroups have one high outlier. I might be changing my opinion about whether the immunization worked, or at least formulating some confirmatory tests that might be used to shed light on the question.

2.2.2

TRANSFORMATIONS IN EXPLORATORY DATA ANALYSIS

Tukey advocated transformation (the most common being logarithmic and square root) as the next logical step in EDA when one has skewed data. Figure 2.3 shows the


11/28/2007 5:50:25 PM

32



150,000

100,000

50,000

0

Pre

Post

Immunization status

FIGURE 2.2 Classic Tukey box plots display nonparametric (distribution-free) descriptive statistics. Individual data points are marked by Xs. The waist indicates the group median and the hinges (upper and lower boundaries of the box) indicate interquartile distances. The whiskers (bars) give the ranges, exclusive of outliers. Outliers (more than 1.5 times the hinge spread from the median) are shown by asterisks (there are none in this illustration) and far outliers (more than three times the hinge spread from the median) are shown by circled Xs. The lower hinge cannot be seen in the pre group, because more than five of the nine data points lie close to the origin.

data of Figure 2.2, log transformed to the base 10. Now we can clearly see what was not apparent at all in Figure 2.1, and was only hinted in Figure 2.2. From the location of the median bars, we see that immunization led to a more than 10-fold increase in median antibody titer (104). Further, the data in both groups are more or less symmetrically distributed, one of the key requirements for the legitimate use of a variety of confirmatory statistical tests (explained in Section 2.6). The two far outlying values seen in Figure 2.2, now fit neatly into the distribution.

2.3 ESTIMATES OF DATA LOCATION AND DISPERSION 2.3.1

DATA LOCATION

The median (the midpoint of a series of ordered numbers, where half the values are above and half below) is the first data-location summary statistic to be evaluated in EDA because it does not require any assumptions about the distribution of the data. Additional summary statistics of data location are the arithmetic mean (the numerical average) and the mode (the most prevalent value within a distribution). Although the arithmetic mean is the most widely used statistic, we will see that


11/28/2007 5:50:25 PM


33

6

Log10 reciprocal antibody titer

5

4

3

2

1

Pre

Post

Immunization status

FIGURE 2.3 Box plot of log-transformed antibody data. The base 10 logarithm of the reciprocal titers shown in Figures 2.1 and 2.2 are plotted. Note that the distributions are fairly symmetrical about the waists (medians), and the two values that appeared as outliers in Figure 2.2 are now within 1.5 hinge spreads of the median.

this is not always to the best effect. When data are approximately symmetrically distributed, the median, mean, and mode are very close. As we saw in our EDA example of antibody titers, biological data, and especially immunological testing data, are often highly skewed. To continue with antibodies as an example, titers in a population may consist of individuals with no detectable antibodies, those with low titers, and a very small proportion with extremely high titers. If one were to accept the mode as a summary statistic to characterize the human immunodeficiency virus Enzyme-Linked ImmunoSorbent Assay (HIV ELISA) titers of university students, one would entirely discount the infrequent HIV positive subjects, because the most common result would be zero (or undetectable). The median would also be zero because more than half of the students are seronegative. Likewise, the arithmetic mean would barely register above zero, influenced as it is by the high proportion of subjects without detectable antibody. Although all these summary statistics are technically correct, they may not capture the biology that we seek to explain. Even if one confined the analysis to “positive” subjects, as is the case with tetanus toxoid because all individuals have been immunized some time in the past (Figure 2.4), the left-skewed distribution would result in mean and median values that differ markedly (the mean is higher than the median because the data distribution contains a tail of very high values). Thus, as in our EDA example, the choice of the most informative statistic to summarize data location is dependent on the data distribution. This will be discussed more in Section 2.3.2.


11/28/2007 5:50:26 PM

34

Handbook of Human Immunology, Second Edition Mode median Mean 400 0.4

300

Count

200

0.2

100

0

Proportion per bar

0.3

0.1

6,000

17,000

28,000

39,000

0.0 50,000


FIGURE 2.4 Distribution of antitetanus antibodies in 1000 subjects. Antibody titer was measured in serial dilutions of serum by ELISA and is expressed as a reciprocal titer (i.e., a value of 32 means that the serum the dilution curve crossed the threshold defining a positive result at a 1/32 dilution). The distributions of values is shown as a bar density histogram. Like many measures of immunity, antibody titer is not symmetrically distributed, but rather is left-skewed. Here, the median and modal values are seen to provide a better summary of the data, the mean being influenced by a few, very high values.

2.3.2

DATA DISPERSION

Although it is easy to find graphs in the scientific literature in which group means are compared without recourse to error bars, statistics of location alone do not provide an adequate summary of a set of observations, and certainly do not provide all the information required to compare results from different groups. In addition to location, we need an indication of the spread of individual observations within the group. In EDA, we chose the hinge spread (distance between the beginning of the second quartile and the end of the third) as a statistic that, along with the location of the median, provided useful information about the shape of the data distribution. In confirmatory data analysis, the sample standard deviation (SD) (see Technical Definition 1) is the most widely used and forms the basis for the many statistical tests based on the assumption of a normal or Gaussian distribution. In general, statistical tests, which assume that the data fit a particular distribution are called parametric tests.


11/28/2007 5:50:26 PM


35

Technical Definition 1 Sample Standard Deviation. Experimental data sets are collected to make generalizations about the population from which test data are drawn. The standard deviation is a measure of average absolute difference in individual measurements (xi ), compared to the sample average (x bar). s=

________________ N _2 1 ______

√

N−1

(x − x) ∑ i=1 i

The standard deviation tells us about the relative homogeneity or spread of a sample. It can be used, for example, to compute sample percentiles, or it can be normalized by dividing it by the sample mean to create a scale-independent measure of variability, the coefficient of variation. Before we are ready to use parametric statistical tests (e.g., Student’s t test*), there is something you must know about all tests relying on the normal distribution: The normal model uses only two parameters (mean and standard deviation) to describe your entire data set.

As discussed, these are measures of location and dispersion, respectively. The validity of tests that assume normality depends entirely on how well the data can be described by these two parameters. Figure 2.4 shows more antibody data, this time from a group of more than 1000 subjects. As we have begun to appreciate from Figures 2.1–2.3, antibody distributions are usually left-skewed, and the data in Figure 2.4 are no exception. In particular, notice how the high outlying values cause the mean to be higher than the median or mode. Since the normal distribution is a family of bell-shaped curves that can be described by the mean and SD, we can create such a curve by plugging our sample mean and SD into an equation. Figure 2.5 shows what happens when we do this for the data in Figure 2.4. By definition, the resulting bell-shaped curve has its peak located at the sample mean, and its points of inflection at one SD below and above the mean. At this point, we have to question whether we want to entrust our data analysis to these two statistics. Considering the skewed nature of the distribution and the absence of zero or negative values, a logarithmic transformation looks promising. In practice, a great deal of quantitative, continuous data from immunologic testing is lognormally distributed, so this is the first transformation that one would try. Figure 2.6 shows the resulting distribution of the log-transformed data (bars) and the predicted normal distribution (curve) (see Technical Definifion 2). What an * Student was the pseudonym of William Sealy Gosset, an industrial chemist for the Guinness Brewery in Dublin, Ireland. After discussions with the statistical pioneer Karl Pearson, he developed the t test to monitor the quality of batches of beer. Although he published the test in Pearson’s statistical journal Biometrika [2], he was required by his employer to use a pseudonym, because they considered their monitoring process a trade secret.


11/28/2007 5:50:26 PM

36

Handbook of Human Immunology, Second Edition Mean

1 SD

Mean

Mean + 1 SD

400 0.4

300

Count

200

0.2

100

0

Proportion per bar

0.3

0.1

6,000

17,000

28,000

39,000

0.0 50,000


FIGURE 2.5 Application of the normal model to antibody data. The bars show the actual distribution of the data. The bell-shaped curve shows the normal distribution calculated from the sample mean and SD. One can see that the actual peak of the distribution is of a much lower value than the peak of the curve. It is also disturbing that the lower end of the distribution extrapolates to negative titers, and the upper end does not account for the highest values.

Technical Definition 2 Normal Distribution. The normal distribution forms the basis of many parametric statistics, such as Student’s t test. It is specified by the equation 1___ e –(x−µ)2/(2σ2) _____ σ√2π This equation has only two parameters, the population mean, μ, and the population standard deviation, σ. The entire family of normal curves is generated by varying μ and σ. If you plug μ = 0, σ = 1, and x values of −3 through 3 into this equation, you will get the standard normal curve (which we will see in Section 2.5) spanning three standard deviations above and below a mean of 0. This curve forms the basis of all standard statistical tables. improvement—the mean, median, and mode are virtually identical (3.26, 3.31, and 3.30, respectively). The data themselves appear to be symmetrically distributed about the mean, and even the extreme values are fairly well modeled. However, this is realworld data and there is also a degree of positive Kurtosis (sharper peak with fatter tails, compared to the normal distribution). This is not a disease, but rather a way to quantify


11/28/2007 5:50:27 PM


Mean

1 SD

37 Mode Median Mean

Mean + 1 SD

150

0.16 0.14 0.12

Count

0.10 0.08 0.06

50

Proportion per bar

100

0.04 0.02 0 1 2 3 4 Log10 reciprocal antibody titer

5

0.00

FIGURE 2.6 Distribution of log-transformed reciprocal titers. The mean, median, and mode are virtually identical and the superimposed normal distribution fits the data reasonably well. Although the data are in log10 units, you can get back to the original reciprocal titers by raising the numbers on the x-axis to the 10th power. Alternatively, one could simply plot the x-axis on a log scale and achieve the same effect.

(along with skewness) a departure from the normal distribution. Practically, experience tells that with antibody data, this is just about as good as it gets, and the assumption of normality is a reasonable one. We could then proceed to compare log-transformed titers. Going back to the data in Figures 2.1–2.3, which are naturally paired values (each subject was measured before and after immunization), Student’s paired t test is the most appropriate confirmatory test (Figure 2.7). This test looks at the difference between the pre- and postimmunization values of the individual subjects. In our example, the average subject had a 7.9-fold rise in antibody titer following immunization (Student’s two-tailed test, p = 0.014). This is as good a time as any for a discussion of one- and two-tailed p values. A p value can be put into words as the probability that a difference this great (i.e., 7.9-fold) would occur by chance alone (given the magnitude of the SD between individual differences and the number of paired observations). In the present case, a chance difference of 7.9-fold could be expected only 1 in 71 times (p = 0.014), well below the conventional probability traditionally considered statistically significant (1 in 20, or p = 0.05). Because this is a two-tailed value, we are considering the probability of a 7.9-fold increase or decrease in antibody titer. Some would favor a one-tailed t test (which would yield exactly half the probability, p = 0.007) arguing that we have a prior hypothesis that the only two expected outcomes


11/28/2007 5:50:27 PM

38

Handbook of Human Immunology, Second Edition 6

Log10 reciprocal antibody titer

5

4

3

2

1 Pre

Post Immunization status

FIGURE 2.7 A line graph showing paired pre- and postimmunization log-transformed reciprocal titers. Student’s paired t test calculates the difference between pre- and postvalues for each individual data pair. The mean difference is then tested to determine whether it is significantly different from zero (the famous null hypothesis). In this example, the mean difference was 0.896 ± 0.303 (SEM). Because these log units are not terribly intuitive, it is best to transform them back into something more intelligible. Taking the base 10 antilog of the mean difference (i.e., converting the number from the log domain, back into the linear domain), we get 100.896 = 7.87. This means that the subjects had, on average, a 7.9-fold increase in antibody titer. The t value associated with this value is 3.314, with a two-tailed p value of 0.014.

of immunization are that either the antibody titer remains the same or increases. I find such arguments to be an annoying example of p-value inflation. Although we do not expect immunization to result in a decrease in titer, this is certainly an intelligible possibility, and as such, deserves to be factored into our analysis by the two-tailed test.

2.3.3

DATA SAMPLING

Sampling has a special meaning in statistics. One of the tenets of the scientific method is that we can make inferences about an entire population by examining a sample drawn from that population. It is lost to history whether Student had a more convivial definition of sampling in mind when he invented his famous t test for the Guinness brewery [2]. To bring the subject back to immunology, the notion of sampling means that you do not have to measure the CD4 count of every living person to get a very good estimate of the distribution of CD4 counts in the population. Statisticians make a useful distinction between means and SDs calculated for entire populations, and those estimated from population samples. In educational testing, for example, it is possible to know the mean (location) and SD (dispersion) of


11/28/2007 5:50:27 PM


39

the test scores for the entire population of students taking the examination. In clinical testing, a population can only be sampled to infer normal ranges (i.e., the distribution of scores in subjects without known pathology). In experimental testing, replicate experiments are thought of as representing a sample from an infinite population of identical experiments that could have theoretically been performed. Although this sounds quite incredible, we will see how, by increasing the number of experimental replicates, our estimated mean and SD converge on the mean and SD of this fictitious population of all possible experiments.

2.4 EFFECT OF SAMPLE SIZE ON PARAMETRIC SUMMARY STATISTICS

19 18 17 16 15 14 13 12 11 10

10 9

SD

Mean

The effect of sampling can easily be seen if we start with a data set in which, like our educational testing example discussed earlier, the results can be known for the entire population. Figure 2.8 shows data for white blood cell (WBC) counts measured on all patients who underwent peripheral stem cell mobilization at the University of Pittsburgh Medical Center between January 1999 and December 2006. To move hematopoietic stem cells from the bone marrow into the blood, these patients are treated with the growth factor granulocyte colony stimulating factor (G-CSF), and their WBCs are monitored for an increase that usually coincides with the peripheralization of hematopoietic stem and progenitor cells. Thus, the counts have much more variability than those of normal subjects. Results from the entire population (1224 determinations) were randomly sampled using increasingly large samples, until the entire population was included. Up to an n of 300, the sample mean oscillates between

5 4

0.8

3

0.7

SEM

CV

7 6

0.9

0.6

2 1

0.5 0.4

8

450

950

N

1450

0

450

950

1450

N

FIGURE 2.8 The figure depicts how the mean, sample SD, CV, and SEM change as a function of the number of observations (N). The data are peripheral WBCs (per microliter in 1000s) from patients receiving the hematopoietic growth factor G-CSF for mobilization of stem cells into their peripheral blood. Data were chosen at random from a set of 1224 observations. Mean, SD, CV, and SEM were calculated with an n of 3, 10, 30, 100, 300, 1000, and the full data set of 1224. The data points are connected by a spline fit. The statistics for the entire population are shown as a dashed line.


11/28/2007 5:50:27 PM

40


10.0 and 18.1, after which the mean stabilizes at about 16.5. The large SD indicates that there is a great deal of patient-to-patient variability. When expressed relative to the mean (in the coefficient of variation [CV]), the SD stabilizes at about 50%. Unlike the mean, SD, and CV, the estimates of which become more precise (not smaller) with an increasing number of observations, the standard error of the mean (SEM) is a measure of how precisely we have estimated the location of the population mean. Accordingly, it decreases as the number of observations grows, and theoretically, would be 0 when the entire population has been sampled.

2.5 STANDARD DEVIATIONS, STANDARD ERRORS, AND WHEN TO USE THEM SDs and standard errors of the mean are the most commonly used statistics to summarize data dispersion in the immunology literature. Now we have seen how the sample mean, SD, and standard error change as the sample size increases, we can apply these statistics to our data with confidence. Bar graphs, line graphs, and dot plots are frequently shown with error bars to help us understand and compare data dispersion. Similarly, we often see numerical data summarized as a value ± another value (e.g. 197 ± 62). Most commonly, these errors are expressed as SDs or standard errors. As seen, these two useful statistics have very different meanings. Despite this, they are sometimes (incorrectly) used interchangeably. Equally incorrectly, error bars or intervals are often used in technical publications without specifying which statistic they represent. The sample SD tells you something about the spread of the data distribution. Use it as a summary statistic (e.g., as an error bar in a graph) when the point is to show the relative homogeneity or heterogeneity of the data. As already mentioned, when you use the sample SD to describe the spread of your data, you are implicitly endorsing the use of the normal distribution to model your data. You accept the premise that your data are well described by a family of symmetrical bell-shaped curves that are completely specified by the sample mean and SD. Your inferences about the location and spread of the population from which your sample was drawn will be correct only to the extent that the normal distribution fits this population. If the model does fit, you can use the SD to infer the upper and lower bounds, which encompass a given proportion of the population data. For example, 95th percentiles are calculated as the sample mean ±1.96 SDs. Referring back to Figure 2.6, one can visualize how approximately two SDs above and below the mean include 95% of the normal distribution, with the remaining 5% lying outside as tails. In Section 2.7.2, we will provide an example where the SD of a measurement sampled from a healthy population is used to infer when an individual value from a patient is within normal limits. Remember that as the sample size (n) increases, the sample SD becomes a more precise estimate of the population SD. It does not become smaller. In this respect, it behaves something like the sample mean. The standard error of the sample mean can be interpreted as a SD describing how means sampled from the entire population vary with respect to one another. Use the SEM (e.g., as an error bar in a graph) when you want to express the precision with which you know the location of the population mean or when comparing the means of


11/28/2007 5:50:28 PM


41

two or more or experimental treatments or groups (to determine the probability that they were drawn from the same population). As we saw in Figure 2.8, the greater the number of observations, the more precise is our estimate of the population mean.

2.6 ASSUMPTIONS OF CONFIRMATORY TESTS Some of the most useful statistical tests rely on the normal distribution. These include Student’s t test, analysis of variance (a generalization of Student’s t test for more than two groups), linear regression analysis, and certain power calculations that are very helpful for experimental design. In addition to the assumption of normality, there are two other requirements that bear some explanation. The first is homogeneity of variance. For comparison of groups, both groups must have approximately equal variance (or equal SDs, the square root of the variance). The sample variances are then pooled to obtain the best estimate of the population variance. For linear regression, the SD of the dependent variable must not change as a function of the independent variable. In practice, a variant of Student’s t test, the unequal variance t test, does not require this assumption, and can be used, provided the data are normally distributed [3]. For linear regression, a dependent variable with a variance that grows as a function of the magnitude of the independent variable will probably behave better after transformation, as we will see in one of our case studies (Section 2.7.3). The second assumption, known as continuity, requires that the universe of possible data values is continuous on the number line. That is, observations can be given to many decimal places arbitrarily. This is never actually the case in the real world where assay precision is limited by instrumentation and data are, in the strictest sense, discontinuous. To pick an extreme example, a hemagglutination assay may call for serum to be serially diluted in twofold increments. The titer is the highest dilution that causes the red blood cells to clump. Here, the only possible assay results (given as reciprocal titer) are 2, 4, 8, 16, etc. Given the assumptions of normality (hemagglutination titers are beautifully lognormally distributed) and homogeneity of variance, can we use Student’s t test to compare data from two groups? Here is how John Tukey reconciled the “unrealism” of the assumption of continuity: “To the man with the data, such unrealism hardly looks helpful, but to the worker with a theory such an assumption turns out to make things simpler. Since all the man with the data can hope for is an approximation, and since an approximation to a few decimal places is often more than he deserves, he soon learns not to worry very often about this particular sort of unrealism.” We may interpret this to mean that continuity is a formal requirement, and for us, the women and men with the data; it is sufficient that continuity of our measurement be intelligible, if not actual. Why do I have to meet these requirements anyway? • When you use a test like Student’s t test to compare the data from groups A and B you are not really comparing the data itself. • When you apply Student’s t test to compare the results of group A and B, you are giving up the raw data in favor of a model that is completely specified by only three numbers: the mean of A, the mean of B, and a pooled SD that is supposed to accurately represent the spread of both groups.


11/28/2007 5:50:28 PM

42


• The test is invalid to the extent that the resulting normal distributions fail to accurately describe the experimental results. • Remember that when the assumptions of normality or homogeneity of variance fail, transformations can often bring the data back into line.

2.6.1

A WORD ABOUT THE NULL HYPOTHESIS

In confirmatory statistics, the interpretation of a test is often related in terms of the null hypothesis. This elicits in most of us a mental cramp, since this double negative (trying to refute the hypothesis of no difference), seems at a first glance the equivalent of trying to prove the hypothesis of a difference (what we students of science usually think we should be doing). This is not the case, as disproving the null hypothesis provides supporting evidence for, but does not prove an alternative hypothesis. Forcing ourselves to see our experimental problems in terms of the null hypothesis, and formulating statistical tests to reject the null hypothesis brings us into line, philosophically, with the falsifiability model of scientific discovery proposed by the twentieth century philosopher Karl Popper [4]. Popper believed that the closest science could come to truth is to provide theories with ample opportunity to be proven wrong by counterexamples. In other words, we gain confidence in a scientific hypothesis by attempting to prove it wrong and failing. Let us return to Figure 2.7 and our paired t test of antibody titers of sera obtained before and after immunization. Because this is a paired t test, the null hypothesis states that there is no difference between titers of individual subjects before and after immunization. To perform the statistical test, we subtract the log of the pre titer from the log of the posttiter. When we test the null hypothesis, we determine the probability that the distribution of resulting post–pre differences could have been drawn from a (hypothetical) population of individuals for whom the mean difference between preand postvalues is zero, and the data dispersion, though unknown, can be estimated from the SD of our sample. Because we have sampled only nine pairs of data from this hypothetical population, the mean difference is very likely, by chance alone, to be a nonzero value. But how different from zero does it have to be before we can reject the idea that our data pairs were drawn from a population of subjects in whom there is no difference before and after immunization? As we have already seen, the mean difference of our sample was 0.896 (not 0) with a SEM of 0.303. A fast and intuitive way of thinking about this problem is to approximate the least significant difference (LSD) at p = 0.05. Just take the null hypothesis mean difference (0), and add two times the SEM (0.606). Is the sample mean difference (0.896) greater? Then we can reject the null hypothesis. Note that this does not formally prove that the immunization worked. There could have been other factors responsible for the rise in titers after immunization, or it could just be bad luck (in Figure 2.7, we found that a difference this large could be expected by chance alone, 1 in 71 times, if the nine data pairs were drawn from a population with a mean difference of 0). It does, however, provide evidence consistent with the notion that immunization caused a rise in titer. Further unsuccessful attempts to falsify our hypothesis (such attempts may include performing similar experiments on additional subjects, or immunizing subjects with a sham immunogen) will give us greater confidence in our conclusion that the vaccine is efficacious.


11/28/2007 5:50:28 PM


43

2.6.2 A WORD ABOUT STATISTICAL SIGNIFICANCE The word significant does two jobs in the language of biomedical science. When we are speaking of a statistically significant difference, we usually mean that we have rejected the null hypothesis because, for example, the probability of two groups of data drawn from the same population is less than 1 in 20 (p < 0.05). This is an arbitrary cutoff, and we may wish to set a more rigorous criterion for statistical significance (say, p < 0.01) if our problem demands that avoiding type I error (false positives, see Technical Definition 3) is more important than avoiding type II error (false negatives). Strictly speaking, this concept of statistical significance applies to comparisons that are performed in isolation. If one were to perform 100 comparisons, then 5 (1 in 20) should turn up spuriously significant at a p value of 0.05, even when no differences exist. In such cases, the Bonferroni correction for multiple comparisons is used to adjust the required p value [5]. Finally, we have the semantic problem of the word significance, and the double job that it does in the language of science. Statistical significance in no way implies significance in the ordinary sense of meaningfulness or importance. We have seen earlier how the SEM decreases with sample size. Thus, with increasing sample size, even small and biologically unimportant differences may grow to be statistically significant. In words attributed to Gertrude Stein, author and Johns Hopkins School of Medicine dropout, “A difference, to be a difference, must make a difference.”

Technical Definition 3 A type I error (or alpha error) is a false positive. In other words, it is rejecting the null hypothesis when it is actually true. The p value is the probability of alpha error. A type II error (or beta error) is a false negative. It means failing to observe a difference when in fact a difference exists (or failing to reject a false null hypothesis).

2.6.3

SENSITIVITY AND SPECIFICITY: POSITIVE AND NEGATIVE PREDICTIVE VALUES

When we are dealing with a test that provides dichotomous outcomes, such as a test to detect a viral infection (positive or negative), we can evaluate it in terms of sensitivity and specificity, which are defined in comparison to a reference or gold standard. The gold standard may be an existing and accepted test, or it may be an outcome that will eventually become known with time, such as the onset of clinical symptoms (e.g., HIV infection). Table 2.1 shows the relationship between a hypothetical-test result and the gold standard. We can see that sensitivity, the ability to identify true positives, is defined as the ratio of true positives to the sum of true positives plus false negatives. Similarly, specificity, the ability to detect true negatives is the ratio of true negatives to true negative plus false positives. Table 2.1 can also be used to conceptualize two other important parameters that depend not only on the test, but also on the prevalence of true positives in the population. These are the


11/28/2007 5:50:28 PM

44


TABLE 2.1 Sensitivity and Specificity Are Defined in Relation to a Gold Standard Gold Standard Test Result Positive Negative

Positive

Negative

TP FN

FP TN

Note: About the test—Sensitivity = TP/(TP + FN), ability to identify TP; Specificity = TN/(FP + TN), ability to identify TN. About the population—Positive predictive value = TP/(TP + FP), will be low when prevalence of TP is low; Negative predictive value = TN/(FN + TN), will be low if prevalence of TP is very high.

positive and negative predictive values of the test. For a test of a given sensitivity and specificity, the positive predictive value will be low when the prevalence of true positives is low. Similarly, the negative predictive value is low when the prevalence of true positives is high. This can be very important in the interpretation of test results. For example, in a blood donor pool that has been prescreened to exclude subjects with risk behavior the prevalence of HIV infection may be very low (say 1/10,000). On screening a million blood products from this donor group, we would expect to find 100 positive samples. Using an assay with 99.9% sensitivity and specificity, we would correctly identify virtually all the 100 positive samples. Of the 999,900 products that are not infected, the test would also correctly identify 999,000 as negative, but would incorrectly find 1000 samples to be HIV positive. Despite the excellent sensitivity and specificity, the positive predictive value is only 9%. We also sometimes use the term sensitivity in the context of quantitative testing, for example, nephelometry is more sensitive than radial immunodiffusion for the measurement of serum immunoglobulin. Here, the term is used to compare the lower limit of detection of the assays. We mean that nephelometry can quantify immunoglobulins down to a lower concentration than immunodiffusion. This is usually related to the signal-to-noise ratio, a term borrowed from electrical engineering. It is based on the assumption that a measurement is an admixture of signal (the parameter that we wish to measure) and noise (a random or irrelevant contribution that contaminates the signal). Sensitivity depends on the relative strengths of signal and noise. In the context of assays of immunity, noise is the intensity of the background or negative control measurement (e.g., optical density of the negative control in an ELISA assay and fluorescence intensity of an isotype control in flow cytometry) and the signal is inferred to be what remains when the background is subtracted from the test result. Sensitivity in this sense can be increased both by strengthening the signal (in flow cytometry using a fluorescent dye with a higher quantum efficiency) or reducing the noise (blocking nonspecific antibody binding). From a statistical perspective, the lower limit of detection can be defined as an upper limit (e.g., 95th percentile) of an appropriate negative control value. For example, the lower limit of detection of an


11/28/2007 5:50:28 PM


45

MHC class I-tetramer assay was defined by determining the mean and SD of the percent of log tetramer positive cells in an MHC mismatched setting (permitting only nonspecific binding). The upper 95th percentile of this negative control, determined to be about 1 in 10,000 cells, was considered to be the lower limit of detection [6].

2.6.4

PRECISION AND ACCURACY

Precision and accuracy are two additional terms that have a specialized meaning in the context of assays of immunity. Precision is closely allied to reproducibility, and reflects the closeness of replicate determinations. The CV (Figure 2.8) among replicate determinations provides an estimate of precision. Like sensitivity and specificity, accuracy relies on comparison to some gold standard. An intuitive example is a pipetting device that may aliquot the same amount of liquid each time within a very close tolerance, but is out of calibration. This device is precise but not accurate. It is entirely possible to be accurate without being precise, and vice versa (Figure 2.9). An example in which the precision of a new assay was determined is shown in Figure 2.10, where a nuclear stain was used to quantify leukocytes contaminating filtered platelet products [7]. Each assay was performed in triplicate and the CV was determined and plotted as a function of the leukocyte count. The assay was very precise at high leukocyte concentrations, but the precision deteriorated rapidly at counts less than 100 cells/mL. Accuracy of the same assay was determined by carefully diluting leukocytes in a sample of known concentration (Figure 2.11). The cell count calculated from the dilution (x-axis) was taken as a gold standard, and the observed results (y-axis) were compared by linear regression analysis. The unexpected nonlinearity at the lower region of the curve may have come from the dilution error, but the model assumes that it is from counting error. Despite this, an intercept near 0 and a slope near 1, and small differences between observed and expected values indicate the accuracy of this assay. Accurate but not precise

Precise but not accurate

FIGURE 2.9 Accuracy and precision are independent attributes. The target on the left-hand side illustrates accuracy without precision (the position of the arrows average to a perfect bull’s-eye), whereas, the arrows on the right-hand side form a tight cluster (high precision) but fail to hit the mark.


11/28/2007 5:50:29 PM

46

Handbook of Human Immunology, Second Edition 45.00

CV (%) triplicate determinations

40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 1

10

100

1,000

10,000

100,000

1,000,000 10,000,000

Leukocytes / mL

FIGURE 2.10 The precision of an assay that measures the leukocyte content of leukoreduced platelet products decreases at lower cell concentrations, as determined by the CV of triplicate determinations.

Observed concentration (cells/mL)

1,000,000 100,000 10,000 1,000 100 10 1 1

10

10

0

1,0

00

10

,00

0 0 10

,00

0 0 ,00

,00

0

1 Expected concentration (cells/mL)

FIGURE 2.11 Careful dilution of a sample of known concentration can be used to create a gold standard (expected concentration) to judge the accuracy of an assay designed to count cells at very low concentration. The sample was diluted in half-log10 increments and assayed in triplicate. There is unexplained nonlinearity at some of the lower concentrations. The lines represent the 95% confidence intervals about the linear regression line of best fit.


11/28/2007 5:50:29 PM


2.6.5

47

STATISTICS AND EXPERIMENTAL DESIGN

The only complaint that statisticians have about experimentalists (and especially immunologists) is that we think about statistics only after getting the results of our experiments. Modern statistical packages contain tools to assist with experimental design, the most important of which are for power analysis. For a two-way comparison, power analysis forces one to think about one’s experiment in terms of the smallest difference that one would care to detect between groups (remember Gertrude Stein), and the degree of data dispersion expected within these groups. In practice, it is like backing into a test of significance. For a real-world example, a graduate student came to me with a data set comparing the expression of an immunophenotypic marker in two groups. After doing a preliminary experiment with two groups, each containing three subjects, he noticed a difference in the hypothesized direction, but on performing a t test, failed to reject the null hypothesis. He decided that the minimal difference in marker expression that he wished to be powered to detect was 25% (a smaller difference seemed to him unlikely to be biologically important). In the example shown in Figure 2.12, his hypothesized results were a mean of 10% in group 1 versus 35% in group 2. From his preliminary data, he estimated the SD

Hypothesized Mean1 = 10 Mean2 = 35 SD = 14.5 Confidence level p = 0.05

Power curve (alpha = 0.050)

1.0 0.9 0.8

Power

0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

5 10 Sample size (group 1)

15

FIGURE 2.12 This is a true example from the doctoral dissertation work of Dr. Aki Hoji, an immunology graduate student at the University of Pittsburgh Graduate School of Public Health. He was comparing phenotypic markers on two T-cell subsets, therefore the data is expressed as percent positive for a given marker. He did a preliminary experiment with three subjects per group. At that time the data looked promising, but had not reached statistical significance. He decided that the minimal difference that he wished to be powered to detect was 25%. That is, a difference of less than 25% expression for a given marker was not deemed to be of biological importance. In the example shown, the hypothesized percent positive were 10 and 35% for the two subsets being compared. This is arbitrary and the same conclusion would have been reached for hypothesized values of 0% versus 25% and 50% versus 75%. The SD (14.5%) was calculated from his preliminary data. The results were encouraging. They indicated that at his present group size (n = 3), he had only a 37% probability of detecting a 25% difference between the groups (at p = 0.05), even if such a difference actually existed. Further, the power calculation indicated that increasing the group size to n = 7 would give him an 84% probability of detecting such a difference.


11/28/2007 5:50:29 PM

48


at 14.5%, and he chose a conventional alpha value (significance level) of 0.05. The results of the power curve, which examines the effect of sample size on power (1—beta error), showed that his preliminary data (n = 3) had only a 37% probability of detecting a 25% difference between the groups, if any existed, at a p value of 0.05. Increasing the sample size to n = 7 increased this probability to 84%. Knowing this, he went back to the bench. To be kosher, the power calculation should have been made before the experiment was initiated, or should have been made using data from an independent set of experiments. Performing interim analyses (taking peeks at the data) influences the meaning of a p value in much the same way that multiple comparisons do. How many mice/patients/samples do you need to complete your experiment? All you need to know is • The assay results conform to the requirements of the test • The smallest between-group difference that you would call biologically meaningful • An estimate of the SD of the assay itself • The alpha level. The p value you will call significant (conventionally at p = 0.05 or less) • How much power you need (usually 0.8, i.e., in 80% of such experiments you would detect such a difference, if it exists, at the stated confidence level)?

2.6.6

A WORD ABOUT NONPARAMETRIC STATISTICS

Nonparametric statistical tests, such as the Wilcoxon signed rank test, the Mann– Whitney U test, the Kruskal Wallace test, and the Spearmen rank coefficient are confirmatory tests based on the rank order of data points rather than their magnitude. They, therefore, do not require the data to conform to a particular distribution, and are not sensitive to the magnitude of outlying values. They can also accommodate data points that are outside the dynamic range of the test (e.g., undetectable and too numerous to count). These tests can be very useful when comparing data that are drawn from a complex distribution, such as one with two or more peaks, or small data sets, where it is difficult to determine the distribution from which the data are drawn. As robust as nonparametric tests are, experience teaches that they are rarely necessary for the vast majority of immunological testing data. Given a data set that can legitimately be analyzed, raw, or in transformation, by tests that rely on normality, an equivalent nonparametric test will often have less statistical power (sensitivity).

2.6.7 2.6.7.1

GRAPHIC REPRESENTATION OF DATA Words of Wisdom Concerning Data Graphics

A picture may be worth a thousand words. Here are a few hundred words about pictures. • Pictures based on exploration of data should force their messages upon us. Pictures that emphasize what we already know—security blankets to reassure


11/28/2007 5:50:30 PM


• • • •

49

us—are frequently not worth the space they take. Pictures that have to be gone over with a reading glass to see the main point are wasteful of time and inadequate of effect. The greatest value of a picture is when it forces us to notice what we never expected to see. John Tukey Less is more. Ludwig Mies Van der Rohe Pie charts are among the most abused graphics icons. We cannot think of a single instance in which a perspective bar graph should be used for any application. A nasty relative of the perspective bar chart is the pseudo perspective bar chart. Illustrators frequently feel the need to make two dimensional bars look like blocks or sky scrapers. Leland Wilkinson [8]

• Forego chartjunk, including moiré vibration, the grid, and the duck.* • The task of the designer is to give visual access to the subtle and the difficult—that is, the revelation of the complex. Edward Tufte [9] 2.6.7.2

Practical Advice on Data Presentation

• Watch your proportions. In the olden days, presentation data were shown using 35-mm slides that have an aspect ratio (width/height) of 1.55:1. Today, most of our graphics end up in PowerPoint, which has an aspect ratio of 1.33:1. Therefore, graphs, tables, and word charts should be about 30% wider than tall. A significant departure means wasted space and a graphic that will read smaller when projected on a screen. • “Wider-than-tall shapes usually make it easier for the eye to follow from left to right ... smoothly-changing curves can stand being taller than wide, but a wiggly curve needs to be wider than tall” (John Tukey). • Choose backgrounds carefully. White is fine for print, but creates a terrible glare when projected in a large auditorium. I personally prefer a light gray, but deep blue with white letters can also be effective in a retro kind of way, in imitation of diazo print photographic slides. • For publication graphics, anticipate the final size of the printed graphic. Choose the type size and the line thickness accordingly. Letters should not clot when they are reduced (e.g., as when the upper half of the lower case “e” fills in). Likewise, lines should not become so thin that they fade. • Choose fonts carefully. Sans serif fonts (e.g., Ariel and Helvetica) tend to look cleaner, but words are more easily recognized by sight when seriffed fonts (e.g., Times Roman and Georgia) are used.

* Tufte defines chartjunk as ink that does not tell the viewer anything new. This includes all forms of spurious or superfluous decoration and especially computer-generated grids and crosshatching patterns that cause the Moiré effect: “designs [that] interact with the physiological tremor of the eye to produce the distracting appearance of vibration and movement.” To know more about the duck, see Ref. 8.


11/28/2007 5:50:30 PM

50


2.7 THREE CASE STUDIES 2.7.1

CASE I: THYMIDINE UPTAKE DATA

Uptake of radiolabeled thymidine is a tried and true method for measuring the proliferation of lymphocytes in response to mitogens or specific antigens [10]. Cells are cultured for a sufficient duration to enter the log phase of proliferation, after which they are given a short pulse (usually 4 h) with tritiated thymidine, which is taken up specifically by proliferating cells. The cells are trapped on a filter, washed, and the incorporated thymidine is measured by scintillation spectrometry. The results involve a comparison of signal (label incorporation in cultures exposed to a mitogenic stimulus) and noise (background incorporation of label in the absence of stimulation). In the present example, the data are from an antigenspecific lymphoproliferation test performed on peripheral blood from a series of 76 patients. The results are expressed as net counts per minute (net CPM), that is, the CPM incorporated in the presence of antigen minus the CPM incorporated in a no antigen control from the same sample (Figure 2.13). The net CPM were very skewed, with a median of 1750 and a mean of 11,125, the mean being strongly influenced by a tail of large values. The data were, therefore, log-transformed and evaluated. Zero or negative values, resulting from background counts equal to or greater than the experimental counts (n = 6) were assigned an arbitrary small value of 1 prior to transformation, because logarithms are undefined for these values. In this case, negative values represented less than 10% of the data. A preponderance of negative values would have steered us away from log transformations and assumptions of normality, and toward a nonparametric test. Log transformation went a long way to make our data fit the normal distribution, with a mean of 3.023 (1054 when back-transformed to a geometric mean by taking the antilog, and much closer to the median of 3.243). This can be appreciated in the horizontal notched box plots shown in Figure 2.13. Figure 2.13 also introduces the normal probability plot, another useful and commonly available tool for evaluating data distributions. Here, the ordered data (x-axis) are plotted against the value predicted by the normal distribution (normalized to a mean of 0 and a SD of 1). A linear relationship indicates that the data are well described by the normal distribution and is evidence of the appropriateness of using tests requiring normality. The EDA tools applied in Figure 2.13 point to the same conclusion. Although the log-transformed data are not perfect (there is a hump on the left resulting from negative values and a resulting flattening of the curve [negative Kurtosis]), the transformed data are decidedly better described by the normal distribution than are the raw data. This is about all one can expect from real-world data. As mentioned earlier, the use of t tests, analysis of variance (a generalization of the t test for multiple groups), linear regression analysis, and several other statistical tests depend on the assumption that the data are normally distributed. Often immunological data are not. When data are not normally distributed, the mean and SD are poor summary statistics. The greater the departure from normality, the less sensitive the test is to detect real differences in the data. Many types of immunological data are log-normally distributed. Examples include radionuclide


11/28/2007 5:50:30 PM


51

Expected value

Mean

Mean

3

3

2

2

1

1

0

0

1

1

2

2

3

3

70

Count

50 40 30 20 10 0

0 00 00 00 00 00 00 00 00 ,0 ,0 ,0 ,0 ,0 ,0 ,0 ,0 10 20 30 40 50 60 70 80 Net CPM

0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0

20 15

0.2

10 0.1 5 0 0

1

2 3 4 Log10 net CPM

5

Proportion per bar

60

0.0

FIGURE 2.13 Use of notched box plots, probability plots, and histograms to assess the conformance of a data set to the normal distribution. In the top panels, net tritiated thymidine uptake (net CPM) and the log transform of net CPM are displayed as normal probability plots, where the x-axis shows ordered observed results, and the y-axis shows results predicted by the normal distribution. The linearity of the resulting relationship indicates the normality of the data. The probability plots are flanked by notched box plots, a variation of the box plot in which the notches at the waist show the 95% confidence interval about the median. The lower panels show histograms with superimposed normal distributions calculated from the data means and standard deviations, comparable to those shown in Figures 2.5 and 2.6. The CV of the raw data is 158% compared to a CV of 46% for the log-transformed data.

uptake, antibody titers, absolute blood counts, MHC tetramer binding frequencies, precursor frequencies, fluorescence intensity of cell surface immunophenotypic markers, and frequencies of rare populations detected by flow cytometry. When such data have been log transformed, the mean and SD better represent the data, tests depending on these parameters are more sensitive, and summary statistics are more appropriate. Before we leave the effects of log transformation on radioactive thymidine uptake data, let us consider a comparison of the lymphoproliferative responses of two groups of 175 subjects each (Table 2.2). Samples of increasing size (n) were drawn from this data set at random. The sampled data were compared by Student’s t test using the raw


11/28/2007 5:50:30 PM

52


TABLE 2.2 Student’s t Test Performed on CPM Data from Two Groups Mean CPM (Groups 1 and 2)

p Value (Two Tailed)

N

Arithmetic

Log

Geometric

Raw Data

Logged

3 10 30 175

2960, 6293 1890, 3180 1980, 4675 1949, 4826

3.465, 3.703 3.239, 3.445 3.262, 3.546 3.248, 3.550

2951, 5045 1734, 2784 1827, 3512 1772, 3547

0.221 0.063 0.001 4 × 10−14

0.369 0.040 7 × 10−5 6 × 10−23

Note: Samples of increasing size were drawn at random from a dataset containing 175 observations per group.

data (arithmetic means) or geometric means. The geometric mean is obtained by log transforming the data, taking the average, and then back transforming the average to the linear domain by taking the antilog. At n = 3 (three subjects per group), group 2 appears to have a higher mean than group 1, but the comparison is not statistically significant. An independent sample of 10 subjects yields statistical significance using both raw and log-transformed data, but the p value is somewhat smaller using logs. In this data set, the superiority of log transformation is most evident when n is large. This case study demonstrates both the practical advantages of transforming the data to better to conform to normality, and the incredible robustness of Student’s t test, which manages to provide the correct answer, albeit with some loss of sensitivity, even if the assumption of normality is flagrantly violated. It is worth noting here that despite our insistence on the importance of transformation, the central limit theorem states that no matter what the shape of the population distribution, the sampling distribution of the mean approaches normality as the sample size increases. However, a very large sample size is required before a highly skewed distribution converges to normality, and we rarely have this luxury with experimental data.

2.7.2

CASE II: T-CELL RECEPTOR HETEROGENEITY AS MEASURED DISTRIBUTION

BY THE V-BETA

The antigen receptors on T-cell clones acquire their incredible diversity by a process involving gene rearrangement and mutation at splice sites (see details in Chapter 6). One of the elements contributing to receptor diversity is the 57-member v-beta gene family that codes for the variable portion of the T-cell receptor beta chain [11]. Only one v-beta specificity is expressed on a given T cell or its clonal descendants. Since 24 of the 57 members account for more than 75% of all TCR v-beta usage, a panel of 24 antibodies can be used to classify the majority of human T cells. v-beta usage within these 24 families follows a characteristic distribution, with some members representing a larger proportion of the T cell population than others. At most, a given specificity will represent 10% of the total T cells, but most are much less prevalent.


11/28/2007 5:50:31 PM


53

This is illustrated in Figure 2.14, which shows the v-beta distribution on CD4+ T cells from 21 healthy subjects. Applying a Gaussian model to our data (Figure 2.15), we can determine normal ranges for each v-beta specificity, arbitrarily defining individual v-beta deletions and expansions as outside the bounds of the 2.5th and 97.5th percentiles, respectively, of the normal distribution calculated from the means and SDs of our data. For each v-beta specificity, we expect, by definition, a frequency of 2.5% expansions and 2.5% deletions in our healthy population. We can check this by applying the calculated cutpoints to our control data set. Given that we have measured 24 v-beta specificities in 21 subjects, we would expect to find, on average 12.6 deletions and 12.6 expansions (24 × 21 × 0.025 = 12.6). However, when we apply our cutpoints, we get 25 expansions and only three deletions. What went wrong? To find out, let us examine our assumptions about normality. Lest you begin to think that all immunological data require transformation, let us

Fraction positive

0.20

0.15

0.10

0.05

0.00 V2

_4 1_4 7_4 2_4 1_4 8_4 3_4 9_4 1_4 3_4 2_4 4_4 2_4 0_4 4_4 1_4 6_4 3_4 8_4 6_4 2_4 2_4 1_4 3_4 _ 3 1 V V V V V V1 V2 V13 V1 V2 V1 V7_ V13 V5_ V1 V1 V7_ V5_ V1 V2 V5 V2 V1

v-Beta

FIGURE 2.14 Distribution of v-beta specificities in peripheral blood CD4+ T cells from 21 healthy subjects. Individual v-beta specificities are ordered by prevalence. The circles show individual data points. The bars show the arithmetic mean values, and the error bars represent 1.96 standard deviations about the mean.

Deletion

Lower cut

Expansion

Central 95% (1.96 × SD)

Upper cut

FIGURE 2.15 The Gaussian model can be used to define normal ranges of usage for each v-beta specificity. Deletions and expansions were defined as lying ouside the central 95% of the distribution.


11/28/2007 5:50:31 PM

54

Handbook of Human Immunology, Second Edition CD4+ percent is normally distributed 2 x

7

0.3

6

Count

0.2

4 3

2

0.1

1 0

0

10

20

0.0 30

Proportion per bar

5

Expected value for normal distribution

8

1

0

1

2

0

10

20

30

Percent Percent CD4+

FIGURE 2.16 Distribution of CD4+ cells among lymphocytes. The histogram shows the distribution of the actual data; the superimposed normal curve is calculated from the sample mean and standard deviation. The probability plot confirms the normality of the data.

begin by applying our EDA tools to the percent of CD4+ cells in our 21 samples (Figure 2.16). Visual inspection of a bar histogram of the data, the superimposed normal distribution calculated from the sample mean and SD, and a probability plot all confirm that CD4 expression is normally distributed among lymphocytes of healthy subjects. In Figure 2.17, I have applied probability plots to both raw and log-transformed frequencies of usage for two v-beta specificities, v-beta 1 and v-beta 7.2, demonstrating quite conclusively that v-beta usage is lognormally distributed. In general, this appears to be the case for all measurements of rare events. Figure 2.18 is a reworking of Figure 2.14, using a logarithmic scale on the y-axis to reflect the lognormal distribution of TCR v-beta. Defining deletions and expansions as lying outside the central 95% of the log-transformed control data set, as we did previously on the raw data, we now calculate 12 expansions and 14 deletions among our controls. This is remarkably close to the 12.6 deletions and expansions predicted on the basis of the normal distribution. Unlike the thymidine uptake example, where failure to log transform merely reduced our power to detect a difference, failure to transform TCR v-beta usage data gave us completely erroneous normal ranges. Had we blindly applied the normal range cutpoints calculated from the raw control data to a set of patient data, we would have greatly overestimated the frequency of expansions and underestimated the frequency of deletions, and therefore seriously misread the underlying immunobiology. The following happens if you fail to transform your data when • The sample mean is greater than the sample median (lognormal data is asymmetrical and has a tail of high values). • The SD is larger than it would be for log-transformed values. The example in Figure 2.13 shows that the CV was more than three times greater in the untransformed data.


11/28/2007 5:50:32 PM

Statistics of Immunological Testing Linear scale

(A) 3

3

2

2

Expected ND value

Expected ND value

55

1 0 1

0 1 2

2 3 0.0

0.1

0.2

3 0.00 0.02 0.04 0.06 0.08 0.10 0.12 v-Beta 7.2

0.3

v-Beta 1 Log transformed

(B) 3

3

2

2

Expected ND value

Expected ND value

1

1 0 1

1 0 1 2

2 3 2.0

1.5 1.0 v-Beta 1

0.5

3

4

3

2 v-Beta 7.2

1

0

FIGURE 2.17 v-Beta usage is lognormally distributed. The distribution of two v-beta specificities, v-beta 1 and v-beta 7.2, are shown for both raw (A) and log-transformed (B) results from a larger dataset. The probability plots clearly demonstrate that v-beta usage is more closely modeled by the normal distribution after log transformation.

• The SD does not represent the distance from the mean to the point of inflection of the sample distribution (this is not possible since the distribution is asymmetrical). This greatly throws off percentile (probability) calculations based on the number of SDs above and below the mean. • It takes a greater difference between the means of two groups to attain statistical significance, because the sample SDs are larger.

2.7.3

CASE III: LINEAR REGRESSION AND CORRELATION—PERIPHERAL BLOOD CD34 COUNTS PREDICT THE CD34 DOSE HARVESTED BY LEUKAPHERESIS

Simple linear regression analysis is designed to test a particular hypothesis concerning the relationship between two variables: The dependent variable increases in proportion to the independent variable. The distinction between the independent


11/28/2007 5:50:32 PM

56


Percent positive

100.00

10.00

1.00

0.10

0.01 v-Beta

FIGURE 2.18 Distribution of log-transformed v-beta specificities in peripheral blood CD4+ T cells from 21 healthy subjects. Individual v-beta specificities are ordered by prevalence. The circles show individual data points. The bars show the geometric mean values, and the error bars represent 1.96 standard deviations about the geometric mean.

variable, conventionally plotted on the x-axis, and the dependent variable, plotted on the y-axis, is an important one. The independent variable is like a gold standard; it is assumed to have no variance, whereas, the dependent variable is a measurement that entails inherent variability. An example might be the relationship between the measurement cell number (dependent variable) and time in culture (independent variable), or a response predicted by theory (independent variable), and the actual measured response (dependent variable). There is often the implicit assumption that the independent variable causes changes in the dependent variable. Linear regression assumes that the relationship is a straight line (Figure 2.19) which can be stated as y = a + bx where y = predicted value of the dependent variable a = y intercept of the line b = slope of the line x = value of the independent variable You may have learned the same equation in algebra class as y = mx + b. Simple linear regression analysis uses the method of least squares to determine the line of best fit through a series of data points (pairs of observations) by minimizing the difference between the observed values and those predicted by the linear equation (residuals). Unless the line of best fit passes exactly through each pair of expected and observed values, the intercept (a) and the slope (b) will have variance. We can express this variance in terms of the SDs of the intercept and slope, or by calculating confidence intervals about these parameters. We can also determine the coefficient of correlation (r 2), a parameter that is estimated as 1—the sum of the squared differences between predicted and observed y values (regression sum


11/28/2007 5:50:33 PM


57

y = a + bx

y

b

1 a

x

FIGURE 2.19 A linear relationship between the dependent variable (y-axis) and the independent variable (x-axis) is modeled by an intercept parameter (a) and a slope parameter (b).

of squares), divided by the sum of the squared differences between the predicted y values and the mean of the observed y values (total sum of squares). In other words, it is the fraction of the total variance in the variable y that is explained by the regression of y against the variable x. r 2 is a fraction between 0 and 1, where 0 indicates no correlation and 1 indicates that all the variance in y can be explained by the value of x (i.e., a perfect fit). Unlike regression analysis, there is no assumption that one variable is dependent and the other independent. The correlation coefficient r 2 can be computed between any two measurements, even if both have variance. It is important to remember that a “line of best fit” with its intercept, slope, and r 2 can be calculated for any set of paired values. Even a slope that is significantly different from 0 does not guarantee that a linear relationship exists between x and y. Figure 2.20 shows the line of best fit through a hyperbola, defined by the equation y = 1/x. Despite the high coefficient of correlation (r 2 = 0.915) and a slope significantly different from 0 (−0.301, p < 0.0005), a straight line does not make a very compelling fit. The residual plot (a plot of the difference between observed and predicted values as a function of the estimated value) provides a very powerful EDA tool with which to judge the appropriateness of the linear model. In Figure 2.20, we can see that at increasing values of x, the linear model first underestimates, then overestimates, then underestimates the observed values. Linear regression also assumes that data are normally distributed, continuous, and homoskedastic (here, this means that the variance of y does not change as a function of x). The residual plot can help you assess the homoskedasticity of the data, because the residuals should be evenly distributed across the estimated values in both sign and magnitude.


11/28/2007 5:50:33 PM

58

Handbook of Human Immunology, Second Edition 1.0

0.2

0.9 0.8

Residual

0.1

y

0.7 0.6

0.0

0.5 0.4 0.3 0.5

1.0

1.5

2.0

x

2.5

3.0

3.5

0.1 0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Estimate

FIGURE 2.20 Fitting a linear model to hyperbolic data. The data points plotted on the left were generated from the hyperbolic function y = 1/x. Despite the obvious departure of these data from linearity, the coefficient of correlation was quite high (0.915). The nonrandom distribution of residuals (right-hand side), clearly show the shortcomings of the linear model.

Autologous or matched allogeneic hematopoietic stem cells can be used to rescue the bone marrow of patients treated with high-dose chemotherapy for a variety of hematologic malignancies. The hematopoietic stem cell graft is obtained by administering hematopoietic growth factors such as G-CSF [12]. This causes hematopoietic stem cells to mobilize from the bone marrow into the peripheral circulation. G-CSF is administered for several days after which leukapheresis, a technique that captures WBCs, while returning red cells, platelets, and plasma to the donor, is performed. The duration of treatment required to mobilize stem cells into the blood is variable, especially in patients who have had extensive previous chemotherapy. If you leukapherese the patient too soon, few stem cells are obtained necessitating further leukapheresis. Leukapherese too late and the patient will have to be rested and remobilized at a later time delaying the critical therapy. A biomarker predicting the results of leukapheresis would be most helpful. To determine whether the peripheral CD34 count predicts the cell dose obtained on the same day by leukapheresis, we performed linear regression analysis of the CD34+ cell dose obtained by leukapheresis (measured in CD34+ cells/kilogram of patient body weight) as a function of the peripheral CD34 count (measured in CD34+ cells/μL). Our first order of business would be to determine whether these variables are approximately normally distributed. As we have seen, there are many tools for this, probability plots, box plots, and density histograms among them. For the purpose of this exercise, we will blast ahead with the analysis at our peril, without EDA. Figure 2.21 shows the poor results. The data are crammed against the y-axis. A few very high values are dragging the regression downward (this is called leverage, and is not a good thing). The residual plot tells the complete story. The leftward skewing of the data is even more apparent (departure from normality), and the residuals are small for low values and get larger for high values (heteroskedasticity). The residuals seem pretty evenly distributed around 0 for low values, but are all negative and large for the four highest values (leverage). Had we started with probability plots, we


11/28/2007 5:50:34 PM

59

80,000,000

20,000,000

70,000,000 60,000,000

10,000,000

50,000,000

Residual

Harvested CD34 dose (cells/Kg)


40,000,000 30,000,000 20,000,000

0

10,000,000

10,000,000 0

0 100 200 300 400 500 600 700 800

20,000,000

0 00 ,000 ,000 ,000 ,000 ,000 ,000 00 0 0 0 0 0 0 0,0 0,0 ,00 0,00 0,00 0,00 0,00 0,00 0,00 0,00 0 8 7 4 3 5 6 2 1

Peripheral blood CD34 count (cells/µL)

Estimate

1.0 10,000,000

0.5

Residual

Harvested CD34 dose (cells/Kg)

FIGURE 2.21 Linear regression of CD34 harvest dose as a function of peripheral CD34 count. The individual data points are shown as circles, the least squares line of best fit and its 95% confidence bounds are shown on the left-hand side. A plot of the residuals of regression is shown on the right-hand side.

1,000,000

100,000

10,000

0.0

0.5

1.0

10.0

100.0

1.0

4

Peripheral blood CD34 count (cells/µL)

FIGURE 2.22 CD34 count.

5

6

7

8

9

Estimate

Linear regression of log CD34 harvest dose as a function of log peripheral

would have immediately recognized that both variables are log normal. Figure 2.22 shows what happens when we log transform the data and repeat the regression analysis. The data are fairly evenly spread, and the residuals are much better behaved, although now, at low values some negative residuals with high leverage have popped up (these are after all data from the real world). Most importantly, we have a regression equation of the form as follows: y = 105.1+1.03x, r 2 = 0.94 where y is the predicted CD34 harvest dose in cells per kilogram. This can be used to predict the cell dose that can be expected for a patient with a given peripheral CD34 count. In practice, we were able to greatly improve on this regression equation, using a


11/28/2007 5:50:34 PM

60


technique called multiple linear regression, by factoring in other variables that carried independent information. These included how long the patient was on the leukapheresis machine, how many times the patient had been previously leukapheresed, and the sex of the patient. This has provided a practical tool that is used everyday in the clinic.

2.8 CAVEATS AND HANDY FACTS • Look at the data first. Data analysis should always begin with EDA. You can tell a lot about your data just by plotting them. This includes the shape of the distributions, the presence of extreme values, and the nature of the relationships between variables. EDA tools such as probability plots can help you choose your models and your transformations. • The mean of differences. It is not the same thing as the difference of two means. If data are naturally paired, you usually want to take the mean of individual differences. For example, if you have the data from which you subtract the “background,” the average of these differences is not mathematically equivalent to taking the mean of the data and subtracting the mean background. • Beware of ratios. Ratios are sometimes essential to the analysis of immunological data but they are rarely well behaved from a statistical standpoint. Also, remember that, as mentioned earlier, the average of ratios is not computationally equivalent to the ratio of averages. • Outliers. Victor McKusick, a pioneer of medical genetics, exhorted his students “cherish your exceptions.” Outliers often provide a key to normal biology. In contrast, if you know that technical problems encountered during an experiment explain the outlying values, it is a disservice to leave them in the analysis where they are a known source of noise. Let your conscience be your guide.

2.9

SOME HANDY PROPERTIES OF LOGS ADAPTED FROM TUKEY

• Logs in different bases differ only by multiplicative constants. You can convert a logarithm of base x to a logarithm of base y by dividing it by the base x log of y. For example, to convert a natural logarithm to the base 10, divide it by the natural log of 10. Because one base is as good as another, serial fourfold dilutions of serum, for example, can be treated as arbitrary whole number units: 0, 1, 2 for 1/8, 1/32, 1/128, respectively. After averaging these arbitrary units, the mean can be “back-converted” to a reciprocal titer by the formula: 4x × 8, where 4 is the fold-dilution, x is the titer in arbitrary fourfold units, and 8 is the starting dilution. In the traditional serological literature, this is known as a geometric mean. Another way to get to the same place is to take the logs of the reciprocal titers, average them, and then take the antilog of the average. • Engineers and mathematicians often express logarithms to the base e because e (2.71828183) crops up naturally in a variety of situations involving


11/28/2007 5:50:34 PM


• •

• •

•

2.10

61

derivatives and limits and simplifies calculations. Base e logarithms are known as natural logarithms (ln). In the biological sciences, base 10 logarithms are more common (in fact, they are known as common logarithms) because it is easier for most of us to think in powers of 10 rather than in powers of 2.7: the log10 of 10 is 1, of 100 is 2, of 1000 is 3, etc. The log of 1 is 0 (any base). The log of 0 is undefined. This sometimes poses a problem in the case of data such as CPM above background that can take on 0 or negative values. Most data realists agree that it is acceptable to add an arbitrary small number to data values before taking the log. Thus, radioisotopic data might be transformed as log10 (net CPM + 1). The log of a product is the sum of the logs of the factors: log (x × y) = log x + log y. The difference of log values is a ratio. For example, in base 10 logs, subtracting 3 from 6 is equal to 3. In the linear domain, this translates to 106/103 = 103 or 1,000,000/1,000 = 1,000. The geometric mean is obtained by logging the values, taking their average, and then taking the antilog of the average.

PRESENTING DATA THAT HAVE BEEN LOG TRANSFORMED

Although working in base 10 logarithms gets to be intuitive very quickly, it is always a good idea to plot or tabulate data in the linear domain. This is accomplished by taking the antilog of the logged values. Be aware of the properties of logarithms mentioned. For example, if you need to calculate error bars, the lower limit of your error bar should be 10(mean−SEM) and the upper limit 10(mean+SEM), not 10mean ± 10SEM. You will know that your error bars are correct if they are symmetrical about the mean when plotted on a log scale, but asymmetrical (with the lower bar being shorter) when plotted on a linear scale.

2.11 CLOSING REMARKS This chapter discusses how a handful of exploratory and confirmatory statistical techniques can improve the design and interpretation of immunological experiments. Although immunology has always been a quantitative science, improvements in instrumentation and the direct interface of instruments to computers have allowed us to design more complex experiments in which more parameters are measured with higher resolution and greater dynamic range. Although this is certainly a blessing, it is a mixed one, because the interpretation of experimental results is commensurately more complex and, as we saw in the TCR v-beta example, the chance that rote application of statistical methods will lead to erroneous interpretations is magnified. The key to good data analysis then is to begin with techniques that allow one to visualize the lay of the data before one chooses confirmatory tests that require assumptions about it. One cannot overemphasize the importance of data transformation during the exploratory phase of data analysis. Finally, the end of scientific investigation is to communicate the findings as effectively as possible. In this regard, good graphic


11/28/2007 5:50:35 PM

62


design is almost as critical as good data analysis. On recognizing the power and beauty of EDA data transformation, confirmatory data analysis, and graphical data display, we may find ourselves agreeing with George Bernard Shaw who said that, “It is the mark of a truly intelligent person to be moved by statistics.”

ACKNOWLEDGMENTS This chapter is written from the perspective of a biologist, with data to analyze and present, not a professional statistician. I am deeply indebted to my heroes of data analysis, John Tukey, Leland Wilkinson, and Edward Tufte, who are all statisticians.

REFERENCES 1. Tukey, JW. Exploratory Data Analysis. Addison-Wesley Publishing Company, Reading, MA, 1977. 2. Student (Gosset, WS). The probable error of a mean. Biometrika 6: 1–25, 1908. 3. Ruxton, GD. The unequal variance t-test is an underused alternative to student’s t-test and the Mann–Whitney U test. Behav. Ecol. 17(4): 688–690, 2006. 4. Popper, K. The Logic of Scientific Discovery. Routledge Classic, London, 2002. 5. Shaffer, JP. Multiple hypothesis testing. Annu. Rev. Psychol. 46: 561–584, 1995. 6. Hoffmann, TK, Donnenberg, AD, Finkelstein, SD, Donnenberg, VS, Friebe-Hoffmann, U, Myers, EN, Appella, E, DeLeo, AB, Whiteside, TL. Frequencies of tetramer + T cells specific for the wild-type sequence p53(264–272) peptide in the circulation of patients with head and neck cancer. Cancer Res. 5; 62(12): 3521–3529, 2002. 7. Triulzi, DJ, Meyer, EM, Donnenberg, AD. Leukocyte subset analysis of leukoreduced platelet components. Transfusion 40: 771–780, 2000. 8. Wilkinson, L. SYSTAT, Version 9. SPSS Inc., Chicago, IL, 1999. 9. Tufte, ER. The Visual Display of Quantitative Information. Graphics Press, Cheshire, CT, 1983, 117p. 10. Schellekens, P, Eijsvoogel, VP. Lymphocyte transformation in vitro: Tissue culture conditions and quantitative measurements. Clin. Exp. Immunol. 3: 571–584, 1968. 11. Robinson, MA. The human T cell receptor beta-chain gene complex contains at least 57 variable gene segments. Identification of six V beta genes in four new gene families. J. Immunol. 46(12): 4392–4397, 1991. 12. To, LB, Haylock, DN, Simmons, PJ, Juttner, CA. The biology and clinical uses of blood stem cells. Blood 89: 2233–2258, 1997.


11/28/2007 5:50:35 PM

3 Human Immunoglobulins Robert G. Hamilton CONTENTS 3.1 Introduction .....................................................................................................64 3.2 Properties of Human Immunoglobulins ......................................................... 65 3.2.1 General Immunoglobulin Structural Properties ................................. 65 3.2.1.1 Human Light Chains ............................................................. 69 3.2.1.2 Human Heavy Chains ........................................................... 69 3.2.1.3 Secretory Component............................................................ 69 3.2.1.4 J Chain .................................................................................. 69 3.2.2 Isotype-Unique Structural and Biological Properties ......................... 71 3.2.2.1 Human IgA............................................................................ 71 3.2.2.2 Human IgD............................................................................ 72 3.2.2.3 Human IgE ............................................................................ 72 3.2.2.4 Human IgG............................................................................ 73 3.2.2.5 Human IgM ........................................................................... 74 3.3 Clinical Applications ...................................................................................... 74 3.4 Methods of Quantitation ................................................................................. 77 3.4.1 Specimen Types ................................................................................... 77 3.4.2 Reagents............................................................................................... 77 3.4.2.1 Polyclonal Antibodies ........................................................... 77 3.4.2.2 Monoclonal Antibodies ......................................................... 78 3.4.2.3 International and National Reference Proteins and Serum Standards ............................................................ 78 3.4.3 Assay Designs ...................................................................................... 79 3.4.3.1 Immunodiffusion ..................................................................80 3.4.3.2 Nephelometric–Turbidimetric Assays ...................................80 3.4.3.3 Immunoassay ........................................................................ 81 3.5 Reference Values ............................................................................................. 81 3.5.1 Factors Influencing Immunoglobulin Levels ...................................... 86 3.5.2 Immunoglobulin Reference Intervals .................................................. 87 3.5.2.1 Serum IgG, IgA, IgM, and IgD ............................................. 87 3.5.2.2 Serum IgG Subclasses...........................................................90 3.5.2.3 Urinary IgG, IgA, and IgM ...................................................92 3.5.2.4 Cerebral Spinal Fluid IgG, IgA, and IgM .............................92 3.5.2.5 Serum IgE .............................................................................94 3.5.2.6 Immunoglobulins in Other Fluids.........................................94 63


12/20/2007 1:30:18 PM

64


3.5.3 Human Light-Chain Reference Intervals............................................. 95 3.5.4 Total Serum IgG Levels during Gammaglobulin Therapy.................. 95 3.6 External Proficiency Surveys ..........................................................................97 3.7 Interferences ....................................................................................................99 3.8 Summary ....................................................................................................... 100 Acknowledgments .................................................................................................. 100 Abbreviations ......................................................................................................... 100 References .............................................................................................................. 101

3.1 INTRODUCTION The human immunoglobulins are a family of proteins that confer humoral immunity and perform vital roles in promoting cellular immunity. Five distinct classes or isotypes of immunoglobulins (IgG, IgA, IgM, IgD, and IgE) have been identified in human serum on the basis of their structural, biological, and antigenic differences.1–4 IgG and IgA have been further subdivided into subclasses IgG1, IgG2, IgG3, and IgG4 or subclasses IgA1 and IgA2 on the basis of unique antigenic determinants.5,6 Multiple allotypic determinants in the constant region domains of human IgG and IgA molecules as well as kappa (κ) light chains indicate inherited genetic markers. Finally, there are several immunoglobulin-associated polypeptides such as secretory component (SC) and J chain that have no structural homology with the immunoglobulins, but serve important functions in immunoglobulin polymerization and transport across membranes into a variety of secretions (e.g., saliva, sweat, nasal secretions, breast milk, and colostrum). This diversity of the immunoglobulin components of the humoral immune system provides a complex network of protective and surveillance functions (e.g., see the role of immunoglobulins in the gastrointestinal tract in Chapter 13 by Guandalini). From a clinical perspective, quantitative levels of these analytes in serum can aid in the diagnosis and management of immunodeficiency, abnormal protein metabolism, and malignant states (e.g., multiple myeloma). As such, they provide a differential diagnosis as to possible causes of recurrent infections and can indicate a strategy for subsequent therapeutic intervention. However, the reported target ranges of each immunoglobulin vary widely as a result of differences in the quantification methods, reagents employed, and populations studied. To date, no compendium of information is available that summarizes the levels of immunoglobulins in healthy pediatric and adult populations in an attempt to provide a consensus for reference intervals on which action levels can be based. The goals of this chapter are threefold. First, primary structural and biological properties of human immunoglobulins are overviewed to highlight their antigenic diversity, which is the basis on which they are quantified. Second, the design and performance of the clinical laboratory methods that are used in the quantification of immunoglobulins are discussed within the context of available commercial and research reagents and their performance in interlaboratory proficiency surveys. Finally, a reference compendium has been prepared that summarizes the ranges of the immunoglobulins in the serum, urine, and cerebral spinal fluid (CSF) of healthy populations, where possible, as a function of age and sex and other demographic variables.


12/20/2007 1:30:19 PM

Human Immunoglobulins

65

3.2 PROPERTIES OF HUMAN IMMUNOGLOBULINS 3.2.1

GENERAL IMMUNOGLOBULIN STRUCTURAL PROPERTIES

Immunoglobulins are functionally defined as glycoproteins that possess the ability to bind to substances (antigens) that have elicited their formation. Tables 3.1 and 3.2 summarize many of the known physical and biological properties of the human immunoglobulin heavy and light chains, SC, J chain, and the five classes of intact immunoglobulins. As a group, the immunoglobulins are composed of 82–96% polypeptides and 4–18% carbohydrate, and they account for approximately 20% of all proteins in plasma.3–5 When placed in porous agarose gels along with other serum proteins under current and selected ionic conditions, most immunoglobulins along with C-reactive proteins migrate toward the cathode, forming a broad band that has been labeled the classical gamma-globulin region. Heterogeneity in their composition and net charge causes some immunoglobulins to also migrate more toward the anode, overlapping with hemopexin, transferrin, and a variety of other proteins in the betaglobulin region.4 As a family, the human immunoglobulins share a basic structural unit that is composed of four polypeptide chains, which are held together by both noncovalent forces and covalent disulfide bonds among their heavy chains, and with the exception of IgA2, also between their heavy and light chains.1,3–5 Each four-chain unit is bilaterally symmetrical, containing two structurally identical heavy (H) chains and two identical light (L) chains (e.g., H2L2). Each polypeptide chain is composed of a number of domains comprising 100–110 amino acid residues, each forming a loop as a result of intrachain disulfide bonds. The N-terminal domain of each chain contains the area designated as the variable or V region. The V region contains several highly variable or hypervariable regions that together form the antigen-binding pocket that confers the property of antigen specificity on the immunoglobulin molecule. The COOH-terminal domains (CH1, hinge, CH2, CH3, and CH4) have been collectively defined as the constant region because the polypeptide backbone is generally invariant (with exception of allotypic differences) within a particular class of immunoglobulin. Human IgG4 appears to be unique in the human immunoglobulin family with its apparent functional monovalency.6 An in vivo exchange of IgG half-molecules (one H plus one L chain) occurs that reportedly results in bispecific antibodies that behave in vivo as functionally monovalent antibodies. The structural basis for this abnormal monovalent behavior has been attributed to the substitution of serine in the hinge region for a proline, which results in a marked shift in the equilibrium between inter- and intrachain disulfide bridges. The consequence is that 25–75% of the IgG4 molecules lack a covalent interaction among the heavy chains. Strong noncovalent interactions among the CH3 domains, however, cause IgG4 to remain stable four-chain molecules that do not easily exchange half-molecules under standard physiological conditions.7 From a clinical laboratory point of view, the constant region structure is vital to the design of immunoglobulin quantification methods. Assays are constructed using poly- and monoclonal antibody (MAb) reagents that bind to nonallotypic, invariant, isotype-unique determinants in the immunoglobulin constant region domains.


12/20/2007 1:30:19 PM


Note: NA = not available. a Approximate MWs.

Associated isotypes Subclasses or subtypes Allotypes Molecular weight (D)a V-region subgroups Carbohydrate average % No. of oligosaccharides

Designation

Property

All — Km(1)–(3) 23,000 VKI-IV 0 0

κ

λ All 1–4 — 23,000 VLI-VI 0 0

Light Chains α IgA 1–2 A2m(1)–(2) 55,000 VHI-IV 8–10 2–3

TABLE 3.1 Human Immunoglobulin Chain Characteristics

δ IgD — — 62,000 VHI-IV 18 NA

IgE — — 70,000 VHI-IV 18 5

ε

γ IgG 1–4 Gm(1)–(25) 50,000–60,000 = g3 VHI-IV 3–4 1

Heavy Chains µ IgM 1–2 — 70,000 VHI-IV 12–15 5

J IgA–IgM — — 15,000 — 8 1

SC IgA — — 70,000 — 16 NA

J Chain

Secretory Component

66 Handbook of Human Immunology, Second Edition

12/20/2007 1:30:20 PM


Distribution (% intravascular)15 Biological half-life (days)3,15 Fractional catabolic rate (% intravascular pool catabolized per day) Synthetic rate (mg/kg/day)3,15

Heavy-chain domain no. Hinge (amino acids) Interchain disulfide bonds per monomer pI range mean (SD) Tail piece Allotypes

Heavy-chain class Light-chain type Averaged Ig light-chain κ/λ ratio15 Molecular weight (D) of secreted forma

IgA2 α2 κ and λ 1.6 160,000m 350,000d 4 5

Yes A2m(1), A2m(2)

57 ± 2 4.5 ± 0.3 32 ± 4

4.3 ± 1

IgA1 α1 κ and λ 1.4 160,000m 300,000d 4 18

Yes None

55 ± 4 5.9 ± 0.5 24 ± 2

24 ± 5 0.4

2–8 37

75

Yes None

4 Yes

180,000m

δ κ and λ

IgD

0.002

1–5 71

50

No Em1

5 None

190,000m

ε κ and λ

IgE

TABLE 3.2 Structural and Biological Properties of Human Immunoglobulins

33

21–24 7

33

21–24 7

45

7.4 (0.6) No G2m: n(23)

8.6 (0.4) No G1m: a(1), x(2), f(3), z(17)

45

4 12 4

150,000m

γ2 κ and λ 1.1

IgG2

4 15 2

150,000m

γ1 κ and λ 2.4

IgG1

33

7–8 17

8.3 (0.7) No G3m: b1(5), c3(6), b5(10), b0(11), b3(13), b4(14), s(15), t(16), g1(21), c5(24), u(26), v(27), g5(28) 45

4 62 11

160,000m

γ3 κ and λ 1.4

IgG3

33

21–24 7

45

7.2 (0.8) No G4m, Gm4a(i), Gm4b(i)

4 12 2

150,000m

γ4 κ and λ 8.0

IgG4

(continued)

3.3

5–10 8.8

80

Yes None

5 None

950,000p

µ κ and λ 3.2

IgM

Human Immunoglobulins 67

12/20/2007 1:30:20 PM


b

a

1–4 0.22 2,4 0 0

11–14 1.81 2,4 0 0

IgA2

0

2 0

0.2

IgD

0

2 0

0.004

IgE

2 ++ ++ ++

5–12

45–53

IgG1

2 + + +

2–6

11–15

IgG2

2 ++ ++ +++

0.5–1

0.03–0.06

IgG3

1–2 ++ ± 0

0.2–1

0.015–0.045

IgG4

5–10 0 0 +++

0.25–3.1

10

IgM

Approximate MW (m = monomer, d = dimer, t = trimer of IgA are produced, p = pentamer). Ranges of immunoglobulins in serum are examined in detail in the text. These ranges are provided as a general indication of target levels. Immunoglobulins rates of metabolism were extracted from Waldmann, T.A., Strober, W., Blaese, R.M., Metabolism of immunoglobulins, in Progress in Immunology, Amos, B., Ed., Academic Press, New York, 1971, pp. 891–903. With permission.

Approximate total Ig in adult serum (%) Adult range: age 16–60 in serum (g/L)b Functional valency Transplacental transfer Binding to phagocytic cells Complement activation classical path

IgA1

TABLE 3.2 (continued) Structural and Biological Properties of Human Immunoglobulins

68 Handbook of Human Immunology, Second Edition

12/20/2007 1:30:20 PM


3.2.1.1

69

Human Light Chains

Human light chains are approximately 23,000 Da proteins that contain no oligosaccharides.4 They have been classified into two types: kappa (κ) and lambda (λ) based on their unique antigenic determinants that result from structural differences in their constant region domains. Based on structural and antigenic differences λ light chains have been further subdivided into four subtypes. The combination of a light chain with a heavy chain is a random process, and thus a complete repertoire of light chains can be found bound to every immunoglobulin isotype heavy chain. It is the heavy chain, therefore, that determines the isotype and the biological effector functions of the immunoglobulin. The kappa to lambda (κ/λ) ratio in the serum of healthy humans is approximately 2:1; however, it can reportedly vary from 1.1 to 8.0 depending on the human immunoglobulin isotype (Table 3.2). 3.2.1.2

Human Heavy Chains

The principal structural characteristics of the five major classes of heavy chains are summarized in Table 3.1. Heavy chains vary in their molecular weight (MW) (50,000–70,000 Da), the percentage of carbohydrates (4–18) and number of oligosaccharides (1–5), number of respective subclasses (IgG1-4 and IgA1-2) and allotypes, number of constant region domains, and number of interchain disulfide bonds. Further details about the structural aspects of the human heavy chains are beyond the scope of this chapter and are presented elsewhere.3–5 Most important to this discussion, the unique antigenic determinants on the heavy chain define the isotype of an immunoglobulin, and thus form the basis on which the different classes of immunoglobulins are differentiated and quantified in the immunoassays discussed subsequently. 3.2.1.3 Secretory Component Human SC is a 90,000-MW glycoprotein that is expressed as an integral protein on the basolateral membrane of mucosal epithelial cells.3,8,9 SC is either released into mucosal secretions as a 70,000-MW soluble fragment or bound to polymers of IgA through strong noncovalent interactions. Structurally, it shares no homology with human heavy or light polypeptide chains or the human J chain. It contains a high carbohydrate content and serves as a receptor to transport IgA across mucosal tissues into various human secretions. Secreted human IgA is composed of two IgA monomers, a J-chain linker, and a molecule of SC. Mucosal secretions contain a mixture of secretory IgA and free SC.10 Highly specific murine MAbs are available (Table 3.3) that bind to selected determinants on the SC and allow their quantification in serum and mucosal secretions.11,12 3.2.1.4

J Chain

The J chain is an elongated glycoprotein of approximately 15,000 Da that can be distinguished by its unusually high quantity of glutamic and aspartic acid residues.3,13 It reportedly serves as a facilitator of polymeric immunoglobulin (e.g., IgM and IgA) polymerization. A single J chain has been identified in each pentameric IgM


12/20/2007 1:30:20 PM

70


TABLE 3.3 Human Immunoglobulin-Specific Murine MAbs Clone HP6017 HP6043b HP6046b HP6069b HP6070 HP6002b HP6014b HP6047b HP6050 HP6023 HP6025b HP6019b HP6030b HP6058b HP6029 HP6061 HP6081 HP6083 HP6086 HP6111 HP6123 HP6054 HP6062 HP6130 HP6141 a

b

Mouse Isotype

Human Ig Specificity

Epitope Specificitya

IgG2a IgG2b IgG1 IgG1 IgG1 IgG2b IgG1 IgG1 IgG1 IgG3 IgG1 IgG1 IgG1 IgG1 IgG1 IgM IgG1 IgG1 IgG1 IgG1 IgG1 IgG2a IgG3 IgG1 IgG1

IgG-PAN IgG-PAN IgG-PAN IgG1 IgG1 IgG2 IgG2 IgG3 IgG3 IgG4 IgG4 IgG1,3,4 IgG2,3,4 IgG1,2,3 IgE IgE IgM IgM IgM IgA-PAN IgA-PAN λ Light chain κ Light chain SC SC

Fc-CH2 Fc-CH2 Fd-CH1 Fc-CH2 Fc-CH2 Fc-CH2 Fd-CH1 Fd-hinge Fd-hinge Fc-CH3 Fc-CH3 Fc-CH2 Fc-CH2 Fc-CH2 Fc Fc Fc Fc Fc Fc Fd — — — —

Designation of the domain to which the IgG-specific MAbs bind have been obtained from Matsson, P., Hamilton, R.G. and Diagnostic Allergy Techniques Working Group. Analytical Performance Characteristics and Clinical Utility of Immunological Assays for Human IgE Antibody of Defined Allergen Specificities: Guideline, Clinical and Laboratory Standards Institute (formally the National Committee on Clinical Laboratory Standards), Wayne, PA, 2007; Jefferis, R., Reimer, C.B., Skvaril, F., De Lange, G., Ling, N.R., Lowe, J., Walker, M.R., Phillips, D.J., Aloiso, C.H., Wells, T.W., Vaerman, J.P., Magnusson, C.G., Kubagawa, H., Cooper, M., Vartdal, F., Vandvik, B., Haaijnan, J.J., Makela, O., Sarnesto, A., Lando, Z., Gergely, J., Rajnavolgyi, E., Laszlo, G., Radl, J., Molinaro, G., Immunol. Lett., 10, 223, 1985; Hamilton, R.G., The Human IgG Subclasses: Molecular Analysis of Structure, Function and Regulation, Pergamon Press, New York, 1990; Reimer, C.B., Phillips, D.J., Aloisio, C.H., Moore, D.D., Galland, G.G., Wells, T.W., Black, C.M., McDougal, J.S., Hybridoma, 3, 263, 1984; Phillips, D.J., Wells, T.W., Reimer, C.B., Immunol. Lett., 17, 159, 1987; Reimer, C.B., Phillips, D.J., Aloisio, C.H., Black, C.M., Wells, T.M., Immunol. Lett., 21, 209, 1989. With permission. The Fd refers to the heavy chain of the F(ab′)2. MAbs specific for human IgG that were selected as components for the polymonoclonal antihuman IgG reagent [43].


12/20/2007 1:30:20 PM


71

or polymeric IgA molecule, covalently bound to the penultimate cysteine residue of mu or alpha heavy chains. From a clinical point of view, the J chain is rarely quantified unless a structural or functional abnormality of this protein is suspected or it is required as a marker to distinguish multiple myeloma from benign gammopathy.13

3.2.2

ISOTYPE-UNIQUE STRUCTURAL AND BIOLOGICAL PROPERTIES

Immunoglobulins are bifunctional molecules that bind antigen through their V region. This binding process can elicit a variety of secondary effector functions (e.g., complement activation leading to bacteriolysis and augmentation of phagocyte chemotaxis and opsonization, and histamine release from mast cells), which are independent of the immunoglobulin’s antigen specificity and depend on C-region determinants (Table 3.2). Although all the five major isotypes of human immunoglobulins share the common structural features of the four-chain monomer subunits discussed earlier, they vary in terms of minor structural aspects that confer some special biological properties. 3.2.2.1 Human IgA Polymeric secretory IgA is composed of two four-chain basic units and one molecule each of SC and J chain (approximately 400,000 MW).3,4,9 It is the predominant immunoglobulin in colostrum, saliva, tears, bronchial secretions, nasal mucosa, prostatic fluid, vaginal secretions, and mucous secretions of the small intestine.8,9 In contrast, 10% of the circulating serum IgA is polymeric, whereas 90% is monomeric (160,000 MW). Together, they constitute approximately 15% of the total serum immunoglobulins. Trimers and higher polymeric forms can exist, but in small amounts. Two subclasses of IgA have been identified (IgA1 and IgA2), which differ by 22 of the 365 amino acids.14 Apart from the 13 amino acid deletion in the IgA2 hinge region, IgA1 and IgA2 constant region domains vary by 20 amino acid substitutions. The IgA1 hinge contains a carbohydrate attachment site, whereas the IgA2 hinge does not. IgA2 is present in two allotypic forms: IgA2m(1) and IgA2m(2). The human IgA PAN-specific murine MAbs listed in Table 3.3 react either to the crystalizable fragment (Fc) or to the antigen binding fragment (Fab) fragment of both subclasses of IgA and both allotypic forms of IgA2. Approximately 80% of the serum IgA is IgA1. In secretions, however, IgA2 concentrations can approach 50% of the total IgA. IgA2 lacks proteolytically sensitive epitopes that makes it particularly resistant to cleavage by enzymes produced by a variety of bacteria (Clostridium spp., Streptococcus pneumoniae, S. sanguis, Haemophilus influenzae, Neisseria gonorrhoeae, and N. meningitidis) that otherwise readily cleave IgA1 into Fab and Fc fragments. The polymeric nature and presence of SC on IgA in secretions increases its resistance to bacterial proteolysis. The IgA2m(1) allotype lacks inter-heavy-chain disulfide bonds. The light chains of IgA2m(2) are linked by disulfide bonds rather than to their respective alpha heavy chain; however, no special biological function has been associated with this unique structural difference.14,15 In terms of complement activation, IgA poorly activates the classical pathway.8 This process has been hypothesized as a host mechanism for attenuating inflammatory responses induced by IgG antibodies at the mucosal surface. In contrast, IgA


12/20/2007 1:30:20 PM

72


reportedly activates the alternative pathway of complement to provide some direct protective functions. IgA, once bound to a bacterial or parasitic surface antigen, may bind CD89 (IgA receptor) on inflammatory cells (monocytes, macrophages, neutrophils, and eosinophils), leading to their destruction by means of antibodydependent cell-mediated cytotoxicity (ADCC). Moreover, its binding to viral or microbial surface antigens may restrict the mobility of microorganisms and prevent their binding to mucosal epithelium. Finally, secretory IgA can play an important first line of defense in antigen clearance by binding to antigens that leak across an epithelium and transporting them back across to prevent their entry.9 To summarize, IgA’s unique structure resists proteolysis and it functions to block uptake of antigen, bacterial or viral attachment, limit inflammation induced by classical pathway complement activation, and promote microbial destruction through ADCC by binding to leukocyte receptors. 3.2.2.2 Human IgD IgD is a four-chain monomer of approximately 180,000 MW with a long hinge region that increases its susceptibility for proteolytic cleavage. Although IgD is normally present in serum in trace amounts (0.2% of total serum immunoglobulin), it predominantly serves as a membrane-bound antigen receptor on the surface of human B lymphocytes.3 Despite suggestions that IgD may be involved in B-cell differentiation, its principal function is as yet unknown. As such, IgD is rarely quantified in a general workup of an individual suspected of a humoral immune deficiency or a B-cell dyscrasia. Hyperimmunoglobulinemia D with serum IgD levels >100 U/mL, however, has been noted in conjunction with periodic fever syndrome.16 This condition is a rare, autosomal recessive disorder that is characterized by recurrent episodes of fever accompanied by abdominal distress, lymphadenopathy, joint involvement, and skin lesions. It appears to be particularly responsive to anti-tumor necrosis factor (TNF) treatment. Mutations that lead to this disease occur in the mevalonate kinase gene, which encodes an enzyme involved in cholesterol and nonsterol isoprenoid biosynthesis. 3.2.2.3 Human IgE IgE (190,000 MW) was identified in 1967 as a unique immunoglobulin that circulates in serum as a four-chain monomer.17,18 Although IgE constitutes only 0.004% of the total serum immunoglobulins, it possesses a clinically significant biological function by binding through its Fc region to the alpha chain on high-affinity receptors (FcεR1) on mast cells and basophils.19 On subsequent exposure to relevant protein allergens from trees, grasses, weeds, pet dander, molds, foods, or insect venoms, IgE antibodies on mast cells become cross-linked. This process triggers the production and release of vasoactive mediators (e.g., histamine, prostaglandins, and leukotrienes) that can induce mild to severe immediate type I hypersensitivity reactions in sensitized atopic individuals. Clinical diagnostic allergy laboratories focus on the quantitation of total serum IgE and allergen-specific IgE to identify an individual’s propensity to develop a spectrum of type I reactions on exposure to a defined panel of 400–500 known allergenic substances (see also Chapter 13 for a discussion on food allergy).20


12/20/2007 1:30:20 PM


73

Total serum IgE is commonly expressed in international units per milliliter (IU/mL) or converted to mass units using 1 IU = 2.44 ng of protein. Recently, International System of Units have proposed units in which1 SI = 1 µg/L; however, these units have not been widely adopted in clinical immunology laboratories that perform allergy testing. In 2003, omalizumab was licensed by the U.S. Food and Drug Administration (FDA) for use in the management of asthma. Omalizumab is a humanized IgG1 antihuman IgE Fc MAb that binds to the region on the epsilon heavy chain that interacts with the alpha chain of the FcεR1. This interaction blocks IgE binding to FcεR1 and downregulates the number of FcεR1 receptors on mast cells and basophils. Important to this chapter on immunoglobulin quantification is the observation that the presence of exogenously administered anti-IgE (omalizumab) in serum degrades the accuracy of some but not all total and allergen-specific IgE assays.21 This issue is discussed in Section 3.7. 3.2.2.4

Human IgG

In healthy adults, the four polypeptide chain IgG monomer (150,000 MW) constitutes approximately 75% of the total serum immunoglobulins.3,4 IgG is approximately equally distributed between intra- and extravascular serum pools. Moreover, IgG possesses the unique ability to cross the placenta, which provides protection for the fetus and newborn. Human IgG has been subdivided into four subclasses on the basis of unique antigenic determinants. Table 3.2 summarizes major structural and biological differences among the IgG subclasses. Relative subclass percentages of the total IgG in serum are IgG1, 60–70%; IgG2, 14–20%; IgG3, 4–8%; and IgG4, 2–6%.3,5,22 IgG1, IgG2, and IgG4 possess an MW of approximately 150,000, whereas IgG3 is heavier (160,000 MW) as a result of an extended 62-amino acid hinge region that contains 11 interchain disulfide bonds. IgG3’s highly rigid hinge region promotes accessibility of proteolytic enzymes to sensitive Fc cleavage sites, which results in an increased fractional catabolic rate and a shorter biological halflife (7–8 days) than has been observed for IgG1, IgG2, and IgG4 (21–24 days). In terms of complement activation, IgG1 and IgG3 are the most effective, whereas IgG4 due to its compact structure does not readily activate the classical pathway of complement. IgG4 antibodies are also unique in that they appear to be functionally monovalent due to in vivo exchange of IgG4 half-molecules.6,7 As such, this is believed to lead to the formation of small IgG4 immune complexes that have a low potential for inducing immune inflammation. Moreover, IgG4 antibodies have the ability to interfere with immune inflammation caused by the interaction of complement-fixing IgG subclasses with antigen. Researchers in the field of allergy have speculated that IgG4 antibodies also scavenge antigen that prevents mast cell-bound IgE antibody from being cross-linked by antigen, and thus blocking IgE-mediated hypersensitivity reactions in atopic individuals who have undergone immunotherapy. Other important structural and biological differences among the human IgG subclasses relate to their Fc receptor binding, and the different binding sites on the constant region domains for rheumatoid factors, complement components, and bacterial proteins (protein A and protein G). The reader can refer to several reviews that discuss these differences in detail.5,22,23


12/20/2007 1:30:20 PM

74


3.2.2.5 Human IgM IgM is a pentameric immunoglobulin of approximately 900,000 MW that is composed of a J chain and five IgM monomers. Pentameric IgM constitutes approximately 10% of serum immunoglobulins in healthy individuals. Along with IgD, monomeric IgM is also a major immunoglobulin that is expressed on the surface of B cells where it serves as an antigen receptor. The C-terminal portion of pentameric secreted IgM differs from that of its monomeric cell-bound form. Secreted IgM has a mu chain with a 20-amino acid hydrophilic tail and a penultimate cysteine that facilitates polymerization. Cell membrane-bound IgM has a 41-amino acid membrane tail that contains a hydrophobic 26-amino acid segment that anchors the IgM molecule in the B-cell membrane lipid bilayer. IgM antibodies are clinically important because they predominate as an antigen receptor in early immune responses to most antigens. With a theoretical functional valency of 10, IgM antibodies are highly efficient in activating the classical complement pathway. IgM’s actual functional valency, however, is only 5 due to steric hindrance among its many antigenbinding sites.3,24

3.3

CLINICAL APPLICATIONS

An immunological workup of an individual who presents with the complaint of chronic or recurrent infections, sometimes with unusual infecting agents, commonly involves the examination for one or more defects in the patient’s antibodymediated (B-cell), cell-mediated (T-cell), phagocytic, or complement segments of their immune system. The level of serum immunoglobulins are commonly measured to identify an underlying defect in the humoral immune system.25,26 There are a variety of primary immunodeficiency disorders (reviewed in Chapter 9) that can produce immunoglobulin patterns ranging from a complete absence of all isotypes of immunoglobulins (e.g., hypogammaglobulinemia) to a selective decrease in a single isotype (selective IgA deficiency). Sometimes, a deficiency in one or several isotypes (e.g., IgG and IgA) can be associated with an elevated level of a third isotype (e.g., IgM). The immunoglobulin profiles of the major primary immunodeficiency diseases are presented in Table 3.4. In the case of hyper-IgE syndrome, levels of IgE in excess of 12,000 ng/mL can be accompanied by a general diminished antibody response following immunization. A spectrum of secondary causes of decreased serum immunoglobulin levels may include malignant neoplastic diseases (e.g., myeloma), protein-losing states (e.g., nephrotic syndrome and protein-losing enteropathy), and immunosuppressive treatment (e.g., transient decrease from corticosteroids). A detailed description of the common symptoms, laboratory findings, other immune markers used in the differential diagnosis of these, and other immunodeficiency disorders is presented elsewhere.26,27 At the other extreme from immunodeficiency are hematological diseases such as plasma-cell dyscrasias that can lead to gross elevations in one or several immunoglobulin isotypes as a result of malignant proliferation of one or several clones of B cells.28 As a group, these conditions are often referred to as paraproteinemias or monoclonal gammopathies and they can be distinguished by the presence of a monoclonal immunoglobulin in the patient’s serum or urine. The laboratory investigation


12/20/2007 1:30:20 PM


< N> N < ?

<

< N> N < ?

>

N <

Handbook of Human Immunology, Second Edition

Handbook of Human Immunology

Atlas of Immunology, Second Edition

Handbook of Human Immunology, 2nd ed

A History of Immunology, Second Edition

A History of Immunology, Second Edition

Illustrated Dictionary of Immunology, Second Edition

Handbook of Vertebrate Immunology

Handbook of Ecotoxicology (Second Edition)

Handbook of Toxicology, Second Edition

Handbook of HPLC, Second Edition

Handbook of Thromboprophylaxis: second edition

Handbook of Ecotoxicology, Second Edition

Handbook of Psycholinguistics, Second Edition

Sensors Handbook, Second Edition

Tribology Handbook, Second Edition

Deja Review Microbiology & Immunology, Second Edition

Immunology Introductory Textbook ~ Revised Second Edition

Understanding Human Rights, Second Edition

Human Brain Function, Second Edition

Principles of Human Evolution (Second Edition)

Human Toxicology of Chemical Mixtures, Second Edition

Human Toxicology of Chemical Mixtures, Second Edition

Handbook of Theories of Aging, Second Edition

Practical Hydraulics Handbook, Second Edition

Public Productivity Handbook, Second Edition,

Environmental Engineers' Handbook, Second Edition

Hazardous Chemicals Handbook, Second Edition

Handbook of Neurocritical Care, Second Edition

Practical Handbook of Microbiology, Second Edition

Handbook of Elastomers, Second Edition, (Plastics Engineering)

Handbook of Human Immunology, Second Edition